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Abstract: Purpose: The aims of this study were to determine if there is seasonal variation in the number of intensive care unit (ICU) admissions for community-acquired pneumonia (CAP) and if there is a relationship between these admissions and weather or reports of influenza-like illness in the community. Materials and Methods: In this time series analysis in 3 medical-surgical ICUs (8, 13, and 20 beds) in the Vancouver region, we included patients admitted to adult ICUs for CAP between January 2002 and March 2006. We used Poisson regression to analyze the association between weekly number of ICU admissions for CAP, and average temperature, range in temperature, total precipitation, and cases of influenza-like illness/100 physician visits reported by sentinel physicians in the community. Results: In 740 patients admitted to ICUs for CAP, admissions peaked each year in the winter-spring months. In multivariate models, a sine function with a single annual peak was independently associated with number of patients admitted to ICU for CAP (rate ratio [95% confidence interval], 1.12 [1.00, 1.26]), but neither the weather measurements nor the weekly rate of reported influenza-like illness was significantly associated. Conclusion: Intensive care unit admissions for CAP are seasonal, but neither weather measurements nor weekly rate of reported influenza-like illness in the community is associated with these admissions. [Copyright &y& Elsevier]

The objective of this study was to determine if timeliness of care would improve after implementation of the team approach in trauma management in a single teaching hospital. To make this determination, we used a before-and-after retrospective cohort series for a 550-bed teaching and tertiary referral hospital that was not a level 1 trauma center. We included all patients who presented to the Emergency Department and who were admitted to St. Paul's Hospital because of trauma during 2 baseline months (May and November 1987; n = 111) and 2 follow-up months (May and November 1990; n = 142). In 1988, a formal trauma team was developed to coordinate the care of trauma patients who were seen in the Emergency Department. Indications for calling the trauma team were based on the criteria of the American College of Surgeons for triage to a trauma center. We calculated elapsed time from assessment in the Emergency Department to arrival of the trauma surgeon, discharge from the Emergency Department, and arrival of the patient in the operating room (for urgent or emergent surgery). We also determined the Revised Trauma Score, the Injury Severity Score (1985 version), the crude mortality ratio, and the Z statistic (population outcome comparison). After implementation of the trauma team, median elapsed time from initial nursing assessment in the Emergency Department to arrival in the operating Room for blunt trauma patients decreased from 11.33 to 4.82 hours (P = .05), but there were no significant differences in any other measures of timeliness, crude mortality, or adjusted mortality. We conclude that implementation of a trauma team in a teaching hospital is associated with a minimal effect on timeliness of care for admitted trauma patients. [ABSTRACT FROM PUBLISHER]

Abstract: Purpose: The aim of this study is to determine if more males than females are admitted to adult intensive care units (ICUs). Materials and methods: In 9 tertiary and community hospitals in British Columbia, Canada, we expressed the number of patients admitted to hospital and to ICU from 1998 to 2008 as a proportion of the population of the main regions served by these hospitals, and for ICU patients in 1 tertiary hospital, as a proportion of the hospital population. Patients not residing in the region of this tertiary hospital or whose addresses were unknown and admissions for sex-specific diagnoses were excluded from the main analyses. Male proportion was divided by female proportion for age groups by decade. Multivariate regression was used to determine the association between sex and admission to ICU after adjustment for confounders. Results: Normalized male-to-female ratio of ICU admissions to the 9 hospitals was greater than 1. In the tertiary hospital analyzed in more detail, the male-to-female ratio for admissions to hospital or to ICU, normalized to the population in the community or hospital, respectively, was greater than 1 for all age groups, and this ratio increased with age. After adjustment for covariates, males and females less than 80 years of age were roughly equally likely to be admitted to ICU from hospital, but in patients aged 80 or older, men were much more likely than women to be admitted (odds ratio, 2.14; 95% confidence interval, 1.56-2.94). Conclusion: More men than women are admitted to ICUs; this difference is especially prominent in elderly patients. [Copyright &y& Elsevier]

Background: The prevalence of physician burnout increased notably during the COVID-19 pandemic, but whether measures of burnout differed based on physician specialty is unknown. The authors sought to determine the prevalence of burnout, worklife conflict, and intention to quit among physicians from different specialties., Methods: This is a cross-sectional online survey of physicians working at 2 urban hospitals in Vancouver, Canada, from August to October 2021. Responses were categorized by specialty (including surgical and nonsurgical), and data about whether physicians provided frontline patient care during COVID-19 were also included. Physician burnout was measured using the Maslach Burnout Inventory., Results: The survey response rate was 42% (209/498). The overall prevalence of burnout was 69%. Burnout was not significantly different by specialty or between frontline COVID-19 specialties compared with other specialties. Physicians in surgical specialties were more likely to report work-life conflict than those in nonsurgical specialties (p = 0.012). Differences in intention to quit among specialties were not statistically significant., Conclusion: During the COVID-19 pandemic, physician burnout was high across physicians, without significant differences between specialties, highlighting the need to support all physicians., Competing Interests: Conflicts of Interest None declared

Objective: To describe the development, implementation and initial evaluation of an initiative to improve glucose control in critically ill patients., Design: Glucose control in critically ill patients was chosen by critical care leaders as a target for improvement. This was an observational study to document changes in processes and measures of glucose control in each intensive care unit (ICU). ICU nurse educators were interviewed to document relevant changes between April 2012 and April 2016., Setting: 16 ICUs in British Columbia, Canada., Participants: ICU leaders., Intervention(s): A community of practice (CoP) was formed, guidelines were adopted, two learning sessions were held, and an electronic system to collect data was created. Then, each ICU introduced their own educational and process interventions., Main Outcome Measure(s): Average hyperglycemic index (area under the curve of serum glucose concentration versus time above the upper limit (10 mmol/l) divided by time on insulin infusion), number of hypoglycemic events (<3.5 mmol/l) divided by time on insulin infusion and standardized mortality rate (actual/predicted hospital mortality) for each 3-month period., Results: Although there were some isolated points and short trends that indicated special cause variation, there were no major trends over time and no obvious association with any of the process changes for each hospital. However, the average hyperglycemic index was higher in some of the smaller hospitals than in the larger hospitals., Conclusions: In this, 4-year observation of glucose control in ICUs within a CoP, the lack of sustained improvement suggests the need for more active and durable interventions., (© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: The purpose of the study is to compare outcomes in patients who had severe hypoxemic respiratory failure (Pao2/fraction of inspired oxygen <100) who received early veno-venous extracorporeal membrane oxygenation (ECMO) as an adjunct to mechanical ventilation, to those in patients who received conventional mechanical ventilation alone., Materials and Methods: This is a multicenter, retrospective unmatched and matched cohort study of patients admitted between April 2006 and December 2013. Generalized logistic mixed-effects models and Cox proportional hazards models were used to determine the association between treatment with ECMO that was started within 3 days of intensive care unit (ICU) admission and ICU and hospital mortality and length of stay, respectively., Results: A total of 2440 patients who had severe hypoxemic respiratory failure due to various etiologies were included, 46 who received early veno-venous ECMO and 2394 unmatched and 398 matched controls who received conventional ventilation alone. Compared to matched controls, ECMO was associated with a lower odds of ICU (odds ratio [95% confidence interval], 0.30 [0.13-0.67]) and inhospital death (odds ratio 0.30 [0.14-0.67]). In addition, ECMO was associated with longer times to discharge from ICU and hospital (hazard ratio, 0.42 [0.37-0.47] and 0.53 [0.38-0.73], respectively)., Conclusions: In this observational study, use of early ECMO compared to conventional mechanical ventilation alone in patients who had severe hypoxemic respiratory failure was associated with a lower risk of mortality and a longer length of stay., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Operations research is the application of mathematical modeling, statistical analysis, and mathematical optimization to understand and improve processes in organizations. The objective of this study was to illustrate how the methods of operations research can be used to identify opportunities to reduce the absolute value and variability of interfacility transport intervals for critically ill patients., Methods: After linking data from two patient transport organizations in British Columbia, Canada, for all critical care transports during the calendar year 2006, the steps for transfer of critically ill patients were tabulated into a series of time intervals. Statistical modeling, root-cause analysis, Monte Carlo simulation, and sensitivity analysis were used to test the effect of changes in component intervals on overall duration and variation of transport times. Based on quality improvement principles, we focused on reducing the 75th percentile and standard deviation of these intervals., Results: We analyzed a total of 3808 ground and air transports. Constraining time spent by transport personnel at sending and receiving hospitals was projected to reduce the total time taken by 33 minutes with as much as a 20% reduction in standard deviation of these transport intervals in 75% of ground transfers. Enforcing a policy of requiring acceptance of patients who have life- or limb-threatening conditions or organ failure was projected to reduce the standard deviation of air transport time by 63 minutes and the standard deviation of ground transport time by 68 minutes., Conclusions: Based on findings from our analyses, we developed recommendations for technology renovation, personnel training, system improvement, and policy enforcement. Use of the tools of operations research identifies opportunities for improvement in a complex system of critical care transport.

Objectives: To describe the qualitative findings from a family satisfaction survey to identify and describe the themes that characterize family members' intensive care unit experiences., Design: As part of a larger mixed-methods study to determine the relationship between organizational culture and family satisfaction in critical care, family members of eligible patients in intensive care units completed a Family Satisfaction Survey (FS-ICU 24), which included three open-ended questions about strengths and weaknesses of the intensive care unit based on the family members' experiences and perspectives. Responses to these questions were coded and analyzed to identify key themes., Setting: Surveys were administered in 23 intensive care units from across Canada., Participants: Surveys were completed by family members of patients who were in the intensive care unit for >48 hrs and who had been visited by the family member at least once during their intensive care unit stay., Interventions: None., Measurements and Main Results: A total of 1381 surveys were distributed and 880 responses were received. Intensive care unit experiences were found to be variable within and among intensive care units. Six themes emerged as central to respondents' satisfaction: quality of staff, overall quality of medical care, compassion and respect shown to the patient and family, communication with doctors, waiting room, and patient room. Within three themes, positive comments were more common than negative comments: quality of the staff (66% vs. 23%), overall quality of medical care provided (33% vs. 2%), and compassion and respect shown to the patient and family (29% vs. 12%). Within the other three themes, positive comments were less common than negative comments: communication with doctors (18% vs. 20%), waiting room (1% vs. 8%), and patient rooms (0.4% vs. 5%)., Conclusions: The study provided improved understanding of why family members are satisfied or dissatisfied with particular elements of the intensive care unit and this knowledge can be used to modify intensive care units to better meet the physical and emotional needs of the families of intensive care unit patients.

Introduction: Mortality from severe sepsis can be improved by timely diagnosis and treatment. This study investigates the effectiveness of a comprehensive management protocol for recognition and initial treatment of severe sepsis that spans from the emergency department (ED) to the intensive care unit., Methods: Interventions included development of a management algorithm including early goal-directed therapy, a computerised physician order entry set for suspected sepsis, introduction of invasive haemodynamic monitoring and antibiotics stocked in the ED, and an extensive education campaign involving ED nurses and physicians., Main Results: In the 6 months after introduction of the protocol, 37 patients who had severe sepsis were identified in the ED. Compared to a randomly selected group of 37 patients who had severe sepsis and who were transferred directly to the intensive care unit before introduction of the protocol, significant improvements were observed in mean time to initiation of early goal-directed therapy (3.2 vs 10.4h, p=0.001) and to achievement of resuscitation goals (10.4 vs 30.1h, p=0.007). There was a trend towards more rapid administration of antibiotics (1.4 vs 2.7h, p=0.06). This was associated with a decrease in crude hospital mortality rate from 51.4% to 27.0% (absolute risk reduction=24%, 95% CI 3% to 47%). Improvements were sustained in the follow-up audit at 16 months., Conclusions: Introduction of a comprehensive management protocol to address early recognition and management of severe sepsis in the ED is associated with sustained improvements in processes of care.

Purpose: Endotracheal intubation (ETI) of critically ill patients is a high-risk procedure that is commonly performed by resident physicians. Multiple attempts (>/=2) at intubation have previously been shown to be associated with severe complications. Our goal was to determine the association between year of training, type of residency, and multiple attempts at ETI., Methods: This was a cohort study of 191 critically ill patients requiring urgent intubation at two tertiary care teaching hospitals in Vancouver, Canada. Multivariable logistic regression was used to model the association between postgraduate year (PGY) of training and multiple attempts at ETI., Results: The majority of ETIs were performed for respiratory failure (68.6%) from the hours of 07:00-19:00 (60.7%). Expert supervision was present for 78.5% of the intubations. Multiple attempts at ETI were required in 62%, 48%, and 34% of patients whose initial attempt was performed by PGY-1, PGY-2, and PGY-3 non-anesthesiology residents, respectively. Anesthesiology residents required multiple attempts at ETI in 15% of patients, regardless of the year of training. The multivariable model showed that both higher year of training (risk ratio [RR] 0.74; 95% confidence interval [CI] 0.54-0.93; P < 0.01) and residency training in anesthesiology (RR 0.52; 95% CI 0.20-1.0; P = 0.05) were independently associated with a decreased risk of multiple intubation attempts. Finally, intubations performed at night were associated with an increased risk of multiple intubation attempts (RR 1.3; 95% CI 1.0-1.4; P = 0.03)., Conclusion: Year of training, type of residency, and time of day were significantly associated with multiple tracheal intubation attempts in the critical care setting.

Objective: To evaluate the impact of prolonged continuous wakefulness on resident performance under controlled experimental conditions., Design: Experimental within-subjects comparison., Setting: High-fidelity patient simulator., Participants: Twelve residents in an Internal Medicine Program at various stages of training (range, 1-35 mos)., Measurements: Performance was studied during 26 hrs of continuous wakefulness at four time points (8:00-10:00 am, 2:00-4:00 pm, 2:00-4:00 am, and 8:00-10:00 am the next day) using high-fidelity patient simulation. At each session, residents managed eight simulated dysrhythmias according to advanced cardiac life support protocols (advanced cardiac life support scenarios) and then managed a simulated critically ill patient (e.g., patient with meningitis) to test more complicated clinical decision-making (complex scenario). The frequency of previously defined major medical errors (i.e., action or inaction that likely would have resulted in significant harm in a real patient) was assessed by a scorer blinded to the time of the session. For each complex scenario, a global score between 0 and 100 was also given for overall performance. The impact of wakefulness on performance was assessed by using longitudinal mixed-effects models., Results: For the complex scenarios, the mean number of errors increased from 0.92 +/- 0.90 in the first session to 1.58 +/- 0.79 in the fourth session (p = .09), and mean global score decreased from 56.8 +/- 14.6 to 49.6 +/- 12.6 (p = .02). For the advanced cardiac life support scenarios, the mean number of major errors committed in the advanced cardiac life support scenarios decreased during the study period (p = .01). However, essentially all of the improvement occurred between the first and second time points, suggesting that a substantial learning effect accounted for the findings., Conclusions: During prolonged continuous wakefulness of medical residents, clinical performance in the management of a simulated critically ill patient deteriorates. The practice of scheduling residents for extended work shifts (>24 hrs) should be reconsidered.

Background: Physicians play a key role in the provision of quality end-of-life (EOL) care but often lack requisite knowledge and skills. Residency programs must ensure training in palliative/EOL care to address this gap., Objective: To guide the development of curricula, we assessed internal medicine residents' attitudes, knowledge, perceived competence, and learning priorities in EOL care., Design: Cross-sectional, self-administered, descriptive survey using a convenience sample., Subjects: Internal medicine residents at five universities across Canada., Results: Of a total of 318 internal medicine residents, 185 (58%) participated in the survey. The majority (81.7%) agreed learning from dying patients was meaningful although 48.1% felt guilty, and 40.6% a failure at least sometimes after a patient's death. Two thirds had provided care to more than 10 dying patients. Most (73%) had conducted at least 3 family meetings; 26.7% were never observed. Mean self-assessed preparedness to provide EOL care was 6.1 +/- 2 (scale 0-10) and mean comfort level 3.2 +/- 0.8 (scale 0-5). Residents reported more than average competence in 50% of EOL competencies listed with record keeping highest (3.6 +/- 0.7) and use of nonpharmacologic interventions for pain lowest (2.2 +/- 0.8). Priority for learning was rated above average for all EOL competencies listed with use of opioids for management of pain highest (4.1 +/- 0.9) and discussing euthanasia lowest (3.1 +/- 1.3)., Conclusions: Internal medicine residents value opportunities to learn from dying patients but often lack supervision and experience emotional distress. Comparing residents' attitudes, perceptions of competence, and learning priorities provide insights into why certain EOL competencies are more challenging to teach and can guide development of meaningful educational experiences.

The purpose of this study was to determine the relationship between ambient workload and outcomes of patients in the intensive care unit (ICU). Measures of workload evaluated for each patient on each day of ICU admission were the number of new admissions, ICU census, "code blue" patients not admitted and Acute Physiology and Chronic Health Evaluation (APACHE) II scores and Multiple Organ Dysfunction Scores (MODSs) for admitted patients. Patients were defined as the patient at risk (the "index" patient) and the other patients in the ICU at the same time (the "non-index" patients). Logistic regression (for hospital mortality) and Cox proportional hazards regression (for time to discharge alive) were used to investigate the association between workload and outcomes. In total, 1,705 patients were included. Higher MODSs of non-index patients on the last day of the ICU admission were associated with lower mortality (odds ratio [OR] 0.82 per MODS point, 95% CI 0.72-0.94). A higher number of code blues during the ICU stay was associated with higher mortality (OR 1.18 per event, 95% CI 1.01-1.37). A higher ICU census and MODS of the non-index patients on the day of ICU admission were associated with a shorter time to discharge alive (hazard rate [HR] 1.03 per patient, 95% CI: 1.01-1.06, and 1.07 per MODS point, 95% CI:1.01-1.15, respectively).The association between measures of ambient workload in the ICU and patient outcomes is variable.Future resource planning and studies of patient safety would benefit from a prospective analysis of these factors to define workload limits and tolerances.

Objective: Intensive care unit (ICU) patients who survive their hospital admission have a long-term survival that is similar to that of hospitalized patients who do not require ICU admission. The risk of future readmission to the hospital for these two patient groups is unknown. The objective of this study was to determine the association between ICU admission and number of readmissions to the hospital and number of readmission days., Design: Cohort study for 3 yrs between 1994 and 1997., Setting: All acute care hospitals in British Columbia, Canada., Patients: A total of 23,859 patients admitted to the ICU and 40,052 patients admitted to the hospital but not the ICU (5% random sample of total)., Intervention: None., Measurements and Main Results: We measured the number of readmissions to the hospital and the number of readmission days after discharge from the first admission to the hospital during the study period. For survivors to the end of the study period, patients who had been in the ICU had 0.66 readmissions per year and 5.29 readmission days per year compared with 0.73 readmissions per year and 5.48 readmission days per year for control subjects. After controlling for age, sex, socioeconomic status, number of previous ICU and hospital admissions, major clinical category during index admission, comorbidity score during index admission, length of hospital stay during index admission, size of index hospital, and period of follow-up, ICU admission was associated with fewer readmissions (survivors: rate ratio, 0.80; 95% confidence interval, 0.77-0.82; nonsurvivors: rate ratio, 0.85; 95%, confidence interval, 0.82-0.89) and readmission days (survivors: rate ratio, 0.91; 95% confidence interval, 0.87-0.95; nonsurvivors: rate ratio, 0.87; 95%, confidence interval, 0.81-0.92) than admission to the hospital but not the ICU., Conclusions: Survivors of a hospital stay that includes admission to an ICU have fewer hospital readmissions and readmission days after their discharge than do survivors of a hospital stay without intensive care.

Objective: To measure the association between intensive care unit (ICU) admission and both hospital and long-term mortality, separate from the effect of hospital admission alone., Design: Retrospective cohort study., Setting: All hospitals in British Columbia, Canada, during 3 fiscal years, 1994 to 1996., Patients: A total of 27,103 patients admitted to ICU and 41,308 (5% random sample) patients admitted to hospital but not to ICU., Intervention: None., Measurements and Main Results: Although ICU admission was an important factor associated with hospital mortality (odds ratio: 9.12; 95% confidence interval: 8.34-9.96), the association between ICU admission and mortality after discharge was relatively minimal (hazard ratio: 1.21; 95% confidence interval: 1.17-1.27) and was completely overshadowed by the effect of age, gender, and diagnosis., Conclusions: After controlling for the effect of hospital admission, admission to ICU has minimal independent effect on mortality after discharge.

Objective: To measure concordance between physicians and medical record coders in their assignment of diagnoses., Design: Prospective cohort series., Setting: Five hundred and fifty-bed, tertiary-care, university teaching hospital. Study participants. In-patients who were discharged from either the Cardiac Sciences Program (n=125), the Renal Program (n=43), or the HIV-AIDS Program (n=25) during the period May 18-July 1, 1995., Interventions: None., Main Outcome Measures: Physicians and coders assigned diagnoses for individual in-patients based on their independent interpretations of the patient chart and discharge summary sheet. All assigned diagnoses were coded using the ICD-9-CM classification system. Concordance was measured for the most responsible diagnosis and for all assigned diagnoses. Difference in calculated resource intensity weights based on physicians' and coders' assignment of diagnoses was also calculated., Results: Concordance rates for the most responsible diagnosis in each program were: Cardiac Sciences [27%; 95% confidence interval (CI)=20-36%], Renal Program (35%; 95% CI=21-53%), and HIV-AIDS Program (20%; 95% CI, 6-41%). Concordance rates for all diagnoses per chart were similar: Cardiac Sciences (20%; 95% CI, 14-25%), Renal Program (25%; 95% CI, 20-33%), and HIV-AIDS Program (29%; 95% CI, 25-44%). Resource intensity weights assigned by coders for the Cardiac Sciences and HIV-AIDS Program were significantly higher than those assigned by the physicians.

Objective: To test the hypothesis that implementation of a practice guideline for blood gas measurement would decrease numbers and increase appropriateness of tests (according to criteria in the guideline) for up to 1 yr after introduction of the guideline., Design: Numbers of tests and appropriateness of each test were measured retrospectively during each of five periods: two baseline periods 2 yrs and 1 yr before introduction of the guideline and three follow-up periods 2 to 3 months, 6 to 7 months, and 12 to 13 months after introduction of the guideline., Setting: A ten-bed multidisciplinary intensive care unit (ICU) within a 500-bed tertiary teaching hospital., Patients: A random sample of 30 patients admitted to the ICU during each of the periods specified above., Interventions: The nominal group process was used to develop a new guideline and a multipronged educational approach was used to facilitate implementation of the guideline., Measurements and Main Results: At 2 to 3 months, test numbers decreased from 4.9 +/- 1.6 to 3.1 +/- 1.8 (SD) tests/patient/day and to 2.4 +/- 1.2 tests/patient/day at 12 to 13 months. Appropriateness increased from a mean of 44% at baseline to 78% at 2 to 3 months and 79% at 12 to 13 months. There were no differences in Acute Physiology and Chronic Health Evaluation scores or ICU mortality among the patient groups and no differences in number of ventilator days or time to wean from ventilation. Cost-minimization analysis showed that the incremental cost-saving 1 yr after introduction of the guideline was $19.18 per patient per day., Conclusions: Implementation of this guideline for arterial blood gas measurement increases efficiency of test utilization without prolonging mechanical ventilation or affecting outcome.

Background: In 1991 the orthopedics department at St Paul's Hospital, Vancouver, British Columbia, Canada, identified the clinical path as a way to shorten length of stay, improve efficiency of resource use, and minimize variation in care processes without compromising clinical outcomes for patients admitted for elective knee or hip arthroplasty., Methods: A team of direct care providers collected baseline data for 77 patients to identify variables influencing length of stay (LOS) and variability in care processes. The team proposed an improved sequence of coordinated clinical decisions and treatments on a daily basis. The clinical path was disseminated by educating nursing and medical staff and by developing pre-printed orders and modifying the nursing care plan., Results: Nine months after implementation of the clinical path, there was a statistically significant reduction in median LOS (12 to 9 days; p < 0.001), which was sustained for at least 18 additional months. Decreased use of inappropriate perioperative antibiotics and laboratory tests and no change in postoperative complications or readmission rate were also found., Discussion: A new team is now developing a clinical path for hip fracture patients. In addition, other programs are using the template employed by the arthroplasty team to develop clinical paths for acute myocardial infarction, coronary artery bypass grafting, stroke, and drug overdose in the intensive care unit., Summary: The team is now working toward a seven-day LOS for these patients. This experience has served as a model for development and implementation of other clinical paths for other groups of patients at the hospital.