PURPOSE:With uncertain prognostic utility of existing predictive scoring systems for COVID-19-related illness, the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) 4C Mortality Score was developed by the International Severe Acute Respiratory and Emerging Infection Consortium as a COVID-19 mortality prediction tool. We sought to externally validate this score among critically ill patients admitted to an intensive care unit (ICU) with COVID-19 and compare its discrimination characteristics to that of the Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores.METHODS:We enrolled all consecutive patients admitted with COVID-19-associated respiratory failure between 5 March 2020 and 5 March 2022 to our university-affiliated and intensivist-staffed ICU (Jewish General Hospital, Montreal, QC, Canada). After data abstraction, our primary outcome of in-hospital mortality was evaluated with an objective of determining the discriminative properties of the ISARIC 4C Mortality Score, using the area under the curve of a logistic regression model.RESULTS:A total of 429 patients were included, 102 (23.8%) of whom died in hospital. The receiver operator curve of the ISARIC 4C Mortality Score had an area under the curve of 0.762 (95% confidence interval [CI], 0.717 to 0.811), whereas those of the SOFA and APACHE II scores were 0.705 (95% CI, 0.648 to 0.761) and 0.722 (95% CI, 0.667 to 0.777), respectively.CONCLUSIONS:The ISARIC 4C Mortality Score is a tool that had a good predictive performance for in-hospital mortality in a cohort of patients with COVID-19 admitted to an ICU for respiratory failure. Our results suggest a good external validity of the 4C score when applied to a more severely ill population.

Sideroblastic anaemia with B-cell immunodeficiency, periodic fever and developmental delay is a recently described, rare syndrome characterised by numerous manifestations underpinned by mutations in transfer RNA nucleotidyltransferase. The pathogenesis arises from mitochondrial dysfunction, with impaired intracellular stress response, deficient metabolism and cellular and systemic inflammation. This yields multiorgan dysfunction and early death in many patients with survivors suffering significant disability and morbidity. New cases, often youths, are still being described, expanding the horizon of recognisable phenotypes. We present a mature patient with spontaneous bilateral hip osteonecrosis that likely arises from the impaired RNA quality control and inflammation caused by this syndrome.

Background: The Serious Illness Care Program (SICP) is a communication intervention that builds clinician capacity to have earlier, more values-based conversations about goals of care with patients experiencing life-limiting illness. We report the impact of its implementation on hospital wards.Methods: In this quality improvement initiative on the medical wards of two Canadian teaching hospitals, we trained physicians, nurse practitioners, and social workers in the use of the Serious Illness Conversation Guide. Between February 2017 and December 2019, we prompted trained clinicians to have serious illness conversations with hospitalized patients or their family member(s), for patients at high risk of dying. Outcomes were the number of clinicians trained, the number of conversations delivered, patient or family experience, including the extent to which they felt heard and understood, and clinician experience.Results: We trained 57 (92%) of 62 eligible clinicians. We delivered conversations to 334 (29%) of 1158 eligible patients (or family members) and documented 274 (82%) of these in the medical record. After a serious illness conversation, 80% of patients or families rated the conversations as mostly or extremely worthwhile and felt more heard and understood (+0.2 on 5-point scale, P = 0.04). The majority (95%) of clinicians agreed (some-what, mostly, or completely) that conversations could be done in an appropriate amount of time and 97% agreed (somewhat, mostly, or completely) that the Guide provided information that enhances clinical care. Interpretation: The SICP can be implemented on medical wards of hospitals and can have a positive impact on patient and clinician experience. RésuméContexte : Le Serious Illness Care Program (SICP) est une intervention de communication qui renforce la capacité du clinicien à avoir des conversations plus précoces et davantage axées sur les valeurs concernant les objectifs des soins avec les patients atteints d’une maladie limitant leur espérance de vie. Nous présentons les répercussions de sa mise en œuvre dans les services hospitaliers.Méthodologie : Dans cette initiative sur l’amélioration de la qualité dans les services médicaux de deux hôpitaux universitaires canadiens, nous avons formé des médecins, des infirmières praticiennes et des travailleurs sociaux à l’utilisation du guide de conversation sur les maladies graves. Entre février 2017 et decembre 2019, nous avons incité les cliniciens formés à avoir des conversations sur les maladies graves avec des patients hospitalisés présentant un risque élevé de décès ou des membres de leur famille. Les critères d’évaluation étaient le nombre de cliniciens formés, le nombre de conversations effectuées, l’expérience des patients ou de leur famille, y compris la mesure dans laquelle ils se sont sentis écoutés et compris, et l’expérience des cliniciens.Résultats : Nous avons formé 57 (92 %) des 62 cliniciens admissibles. Des conversations ont été réalisées auprès de 334 (29 %) des 1158 patients (ou membres de la famille) admissibles et 274 (82 %) de ces conversations ont été consignées dans le dossier médical. Après une conversation sur les maladies graves, 80 % des patients ou de leur famille ont évalué les conversations comme étant plutôt ou extrêmement utiles et ils se sont sentis plus écoutés et compris (+ 0,2 sur une échelle de 5 points, P = 0,04). La majorité (95 %) des cliniciens sont d’accord (quelque peu, plutôt ou complètement) sur le fait que les conversations ont pu avoir lieu dans un laps de temps approprié et 97 % sont d’accord (quelque peu, plutôt ou complètement) sur le fait que le guide fournit des renseignements qui améliorent les soins cliniques.Interprétation : Le SICP peut être mis en œuvre dans les services médicaux des hôpitaux et peut avoir des répercussions positives sur l’expérience des patients et des cliniciens.

The optimal noninvasive modality for oxygenation support in COVID-19-associated hypoxemic respiratory failure and its association with healthcare worker infection remain uncertain. We report here our experience using high-flow nasal oxygen (HFNO) as the primary support mode for patients with COVID-19 in our institution. We conducted a single-centre historical cohort study of all COVID-19 patients treated with HFNO for at least two hours in our university-affiliated and intensivist-staffed intensive care unit (Jewish General Hospital, Montreal, QC, Canada) between 27 August 2020 and 30 April 2021. We report their clinical characteristics and outcomes. Healthcare workers in our unit cared for these patients in single negative pressure rooms wearing KN95 or fit-tested N95 masks; they underwent mandatory symptomatic screening for COVID-19 infection, as well as a period of asymptomatic screening. One hundred and forty-two patients were analysed, with a median [interquartile range (IQR)] age of 66 [59–73] yr; 71% were male. Patients had a median [IQR] Sequential Organ Failure Assessment Score of 3 [2–3], median [IQR] oxygen saturation by pulse oximetry/fraction of inspired oxygen ratio of 120 [94–164], and a median [IQR] 4C score (a COVID-19-specific mortality score) of 12 [10–14]. Endotracheal intubation occurred in 48/142 (34%) patients, and overall hospital mortality was 16%. Barotrauma occurred in 21/142 (15%) patients. Among 27 symptomatic and 139 asymptomatic screening tests, there were no cases of HFNO-related COVID-19 transmission to healthcare workers. Our experience indicates that HFNO is an effective first-line therapy for hypoxemic respiratory failure in COVID-19 patients, and can be safely used without significant discernable infection risk to healthcare workers.

BackgroundPoor communication with hospitalized patients facing serious, life-limiting illnesses can result in care that is not consistent with patients’ values and goals. The Serious Illness Care Program (SICP) is a communication intervention originally designed for the outpatient oncology setting that could address this practice gap. MethodsA multihospital quality improvement initiative adapted and implemented the SICP on the medical wards of four teaching hospitals in Calgary, Hamilton, Ottawa, and Montreal. The SICP consists of three main components: tools (including the Serious Illness Conversation Guide for clinicians), training for frontline clinicians to practice using the Guide, and system change to trigger and support serious illness conversations in practice. Implementation of the SICP at each site followed a phased approach: (1) Building a Foundation; (2) Planning; (3) Implementation; and (4) Sustainability. To assess the success of implementation and its impact, we developed an evaluation framework that includes process measures (e.g., number and proportion of eligible clinicians trained, number and proportion of eligible patients who received a serious illness conversation), patient-reported outcomes (including a validated, single-item “Feeling Heard and Understood” question), and clinician-reported outcomes. ConclusionBased on our adaptation and implementation efforts to date, we have found that the SICP is readily adaptable to an inpatient medical ward setting. Future manuscripts will report on the fidelity of implementation, impact on patient- and clinician-reported outcomes, and lessons learned about how to implement and sustain the program. RésuméContexteUne mauvaise communication avec les patients hospitalisés atteints d’une maladie grave qui limite leur espérance de vie peut se traduire par des soins qui ne correspondent pas à leurs valeurs et à leurs objectifs. Le Programme de soins dans le cas de maladies graves (PSMG) est une intervention de communication conçue à l’origine pour l’oncologie externe qui pourrait remédier à cette lacune dans la pratique. MéthodologieUne initiative multihospitalière visant l’amélioration de la qualité a adapté et mis en œuvre le PSMG dans les unités de soins de quatre hôpitaux universitaires situés à Calgary, à Hamilton, à Ottawa et à Montréal. Le PSMG comprend trois principaux éléments : des outils (dont le guide de conversation sur les maladies graves à l’intention des cliniciens), de la formation pour que les cliniciens de première ligne puissent s’exercer à l’aide du guide et un changement de système pour entamer et faciliter les conversations sur les maladies graves dans la pratique. À chaque endroit, la mise en œuvre du PSMG a suivi une approche progressive : 1) l’établissement d’une base; 2) la planification; 3) la mise en œuvre; 4) la durabilité. Pour évaluer le succès de la mise en œuvre et ses répercussions, nous avons créé un cadre d’évaluation qui comprend des mesures de processus (p. ex., le nombre et la proportion de cliniciens admissibles formés, le nombre et la proportion de patients admissibles qui ont eu une conversation sur les maladies graves), des résultats rapportés par les patients (dont une question validée à un seul élément « se sentir écouté et compris ») et des résultats rapportés par les cliniciens.ConclusionÀ la lumière de nos activités d’adaptation et de mise en œuvre réalisées jusqu’à maintenant, nous constatons que le PSMG est facilement adaptable à un contexte d’unité de soins pour les patients hospitalisés. Les prochains manuscrits porteront sur la fidélité de la mise en œuvre, les répercussions sur les résultats rapportés par les patients et les cliniciens et les leçons apprises sur la façon de mettre en œuvre et de maintenir le programme.

BACKGROUND:Awake prone positioning has been reported to improve oxygenation for patients with COVID-19 in retrospective and observational studies, but whether it improves patient-centred outcomes is unknown. We aimed to evaluate the efficacy of awake prone positioning to prevent intubation or death in patients with severe COVID-19 in a large-scale randomised trial. METHODS:In this prospective, a priori set up and defined, collaborative meta-trial of six randomised controlled open-label superiority trials, adults who required respiratory support with high-flow nasal cannula for acute hypoxaemic respiratory failure due to COVID-19 were randomly assigned to awake prone positioning or standard care. Hospitals from six countries were involved: Canada, France, Ireland, Mexico, USA, Spain. Patients or their care providers were not masked to allocated treatment. The primary composite outcome was treatment failure, defined as the proportion of patients intubated or dying within 28 days of enrolment. The six trials are registered with ClinicalTrials.gov, NCT04325906, NCT04347941, NCT04358939, NCT04395144, NCT04391140, and NCT04477655. FINDINGS:Between April 2, 2020 and Jan 26, 2021, 1126 patients were enrolled and randomly assigned to awake prone positioning (n=567) or standard care (n=559). 1121 patients (excluding five who withdrew from the study) were included in the intention-to-treat analysis. Treatment failure occurred in 223 (40%) of 564 patients assigned to awake prone positioning and in 257 (46%) of 557 patients assigned to standard care (relative risk 0·86 [95% CI 0·75-0·98]). The hazard ratio (HR) for intubation was 0·75 (0·62-0·91), and the HR for mortality was 0·87 (0·68-1·11) with awake prone positioning compared with standard care within 28 days of enrolment. The incidence of prespecified adverse events was low and similar in both groups. INTERPRETATION:Awake prone positioning of patients with hypoxaemic respiratory failure due to COVID-19 reduces the incidence of treatment failure and the need for intubation without any signal of harm. These results support routine awake prone positioning of patients with COVID-19 who require support with high-flow nasal cannula. FUNDING:Open AI inc, Rice Foundation, Projet Hospitalier de Recherche Clinique Interrégional, Appel d'Offre 2020, Groupement Interrégional de Recherche Clinique et d'Innovation Grand Ouest, Association pour la Promotion à Tours de la Réanimation Médicale, Fond de dotation du CHRU de Tours, Fisher & Paykel Healthcare Ltd.

This paper reports findings from a modified World Café conducted at a palliative care professional conference in 2019, where input on tools to support advance care planning (ACP) was solicited from healthcare practitioners, managers and family members of patients. Barriers to ACP tool use included insufficient structures and resources in healthcare, death-avoidance culture and inadequate patient and family member engagement. Recommendations for tool use included clarification of roles and processes, training, mandates and monitoring, leadership support, greater reflection of diversity in tools and methods for public engagement. This paper illuminates factors to consider when implementing ACP tools in healthcare.

BACKGROUND:The coronavirus disease 2019 (COVID-19) pandemic is responsible for millions of infections worldwide, and a substantial number of these patients will be admitted to the intensive care unit (ICU). Our objective was to describe the characteristics, outcomes and management of critically ill patients with COVID-19 pneumonia at a single designated pandemic centre in Montréal, Canada. METHODS:A descriptive analysis was performed on consecutive critically ill patients with COVID-19 pneumonia admitted to the ICU at the Jewish General Hospital, a designated pandemic centre in Montréal, between Mar. 5 and May 21, 2020. Complete follow-up data corresponding to death or discharge from hospital health records were included to Aug. 4, 2020. We summarized baseline characteristics, management and outcomes, including mortality. RESULTS:A total of 106 patients were included in this study. Twenty-one patients (19.8%) died during their hospital stay, and the ICU mortality was 17.0% (18/106); all patients were discharged home or died, except for 4 patients (2 awaiting a rehabilitation bed and 2 awaiting long-term care). Twelve of 65 patients (18.5%) requiring mechanical ventilation died. Prone positioning was used in 29 patients (27.4%), including in 10 patients who were spontaneously breathing; no patient was placed on extracorporeal membrane oxygenation. High-flow nasal cannula was used in 51 patients (48.1%). Acute kidney injury was the most common complication, seen in 20 patients (18.9%), and 12 patients (11.3%) required renal replacement therapy. A total of 53 patients (50.0%) received corticosteroids. INTERPRETATION:Our cohort of critically ill patients with COVID-19 had lower mortality than that previously described in other jurisdictions. These findings may help guide critical care decision-making in similar health care systems in further COVID-19 surges.

INTRODUCTION: Advancements in the care of acutely ill patients has reduced intensive care unit (ICU) mortality but has also led to the emergence of a group of patients who have a prolonged dependency on life support measures. Despite this rapidly growing demographic, a relatively minimal amount is known in the way of identifiable risk factors for outcomes in chronic critically ill patients. We sought to explore the association between admission diagnostic category and acute hospital mortality in chronic critically ill patients. METHODS: The study is a retrospective cohort study of adult patients aged 18 and over, admitted to two Canadian, university associated ICUs between July 2012 and June 2013. We included in our study all patients who had a tracheostomy placed for prolonged mechanical ventilation in the ICU. The primary outcome was ultimate acute hospital mortality. A univariate and multivariate analysis was performed to assess the association of admission diagnostic category and ultimate acute hospital mortality. RESULTS: One hundred and forty-four patients received a tracheostomy in the ICU during the study period with 134 patients eligible for analysis. We demonstrated both baseline characteristics and outcomes differences between medical patients, non-trauma surgical patients and trauma patients. The trauma group had a lower ICU and hospital mortality even after adjusting for potential confounders such as severity of illness and co-morbidities (OR: 0.1 95% CI 0.0-0.3, p < 0.001). They were also more likely to be discharged home or to a rehabilitation center. CONCLUSION: In conclusion, we demonstrated that ICU admission diagnostic category is associated with acute hospital mortality. Chronic critically ill trauma patients were found to have lower acute hospital mortality rates than medical or non-trauma surgical patients even after adjustment for confounders using severity of illness scores that contain variables for admission type. Admission diagnostic category should inform patients, surrogate decision makers and the health care team regarding decisions related to tracheostomy placement and prolonged supportive care.

BackgroundPoor quality communication about goals of care with seriously ill, hospitalized patients is associated with substantial discordance between prescribed medical orders for life-sustaining treatment and patients’ stated preferences. Designing tailored solutions to this discordance requires a better understanding of this communication process. ObjectiveTo acquire a detailed understanding of the process of communication about goals of care and decision making about life-sustaining treatments for hospitalized patients, and to seek opportunities for improvement. SettingMedical wards of three university-affiliated teaching hospitals in Canada. MethodAt each site, we used drop-in sessions and one-on-one interviews to consult with health care workers on eligible wards to create cross-functional (swim lane) maps of the process of communication about goals of care and decision making about life-sustaining treatments. Healthcare workers were also asked about barriers to this process to enable the identification of opportunities for improvement. ResultsA total of 112 healthcare workers provided input into the creation of process maps across the three sites. Common elements across sites were that: (1) physicians play a central role, (2) the full process for a given patient involves several interactions amongst members of the inter-professional team, and (3) the process is iterative. We also noted between-site variations in the location of GoC discussions and the extent to which trainees and multi-disciplinary team members were involved. Finally, we identified several key barriers that may serve as targets for future quality improvement efforts: suboptimal location of conversations, insufficient support of physician learners in goals-of-care conversations, and incomplete engagement of the inter-professional team. ConclusionEfforts to improve the quality of goals-of-care discussions and decision making about life-sustaining treatments in the hospital setting need to account for the central role played by physicians in the process but can be enhanced if they can more fully engage the inter-professional health care team.Resume Contexte Une communication de mauvaise qualité sur les objectifs des soins aux patients gravementmalades et hospitalisés est associée à une discordance importante entre les ordonnances médicales prescrites pour un traitement de survie et les préférences déclarées des patients. La conception de solutions adaptées à cette discordance nécessite une meilleure compréhension de ce processus de communication. ObjectifAcquérir une compréhension détaillée du processus de communication sur les objectifs des soins et la prise de décision sur les traitements de maintien de la vie pour les patients hospitalisés, et rechercher des possibilités d’amélioration. ParamètresLes services médicaux de trois hôpitaux universitaires canadiens affiliés à l’université. MéthodeSur chaque site, nous avons eu recours à des séances d’information et à des entretiens individuels pour consulter les travailleurs de la santé dans les services éligibles afin de créer des cartes interfonctionnelles (couloir de nage) du processus de communication sur les objectifs des soins et la prise de décision sur les traitements de maintien des fonctions vitales. Les travailleurs de la santé ont également été interrogés sur les obstacles à ce processus afin de permettre l’identification des possibilités d’amélioration. RésultatsAu total, 112 travailleurs de la santé ont participé à la création de cartes de processus sur les trois sites. Les éléments communs à tous les sites étaient les suivants : (1) les médecins jouent un rôle central, (2) le processus complet pour un patient donné implique plusieurs interactions entre les membres de l’équipe interprofessionnelle, et (3) le processus est itératif. Nous avons également noté des variations entre les sites en ce qui concerne le lieu des discussions du gouvernement et le degré d’implication des stagiaires et des membres de l’équipe pluridisciplinaire. Enfin, nous avons identifié plusieurs obstacles clés qui pourraient servir de cibles aux futurs efforts d’amélioration de la qualité : le lieu sous-optimal des conversations, le soutien insuffisant des apprenants médecins dans les conversations sur les objectifs de soins et l’engagement incomplet de l’équipe interprofessionnelle. ConclusionLes efforts visant à améliorer la qualité des discussions sur les objectifs des soins et la prise de décision concernant les traitements vitaux en milieu hospitalier doivent tenir compte du rôle central joué par les médecins dans le processus, mais peuvent être renforcés s’ils peuvent faire participer davantage l’équipe interprofessionnelle de soins de santé.

BACKGROUND:The Withdrawal Assessment Tool-1 (WAT-1) has been validated for assessing iatrogenic withdrawal syndrome in critically ill children receiving mechanical ventilation, but little is known about this syndrome in critically ill adults.OBJECTIVE:To evaluate the validity and reliability of the WAT-1 in critically ill adults.METHODS:A prospective, observational, open-cohort pilot study of critically ill adults receiving mechanical ventilation and regular administration of opioids for at least 72 hours. Patients were assessed for withdrawal twice daily on weekdays and once daily on weekends using the WAT-1 after an opioid weaning episode. The presence of iatrogenic withdrawal syndrome was evaluated once daily using modified Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) criteria. All evaluations were blinded and performed independently. The criterion validity of the WAT-1 and the interrater reliability for WAT-1 and DSM-5 evaluations were determined.RESULTS:During 8 months, 52 adults (median age, 51.5 years) were enrolled. Eight patients (15%) had at least 1 positive assessment during their intensive care unit stay using the DSM-5, compared with 19 patients (37%) using the WAT-1. The overall sensitivity of the WAT-1 was 50%, and its specificity was 65.9%. Agreement between WAT-1 and DSM-5 assessments was poor (κ = 0.102). The interrater reliability for the WAT-1 was 89.1% and for the DSM-5 was 90.1%.CONCLUSION:Despite showing reliability, the WAT-1 is not a valid tool for assessing the presence of iatrogenic withdrawal syndrome in adults.

Background Ultrasound is increasingly relied upon to estimate central venous pressure (CVP) in the echocardiography lab and using point-of-care systems in the intensive care unit and the emergency department. However, there is uncertainty regarding the diagnostic accuracy of ultrasound-based parameters as reported in diverse studies.Methods A systematic review was performed by searching MEDLINE, EMBASE, and the Cochrane Database for studies evaluating ultrasound-based indicators of filling pressures in relation to catheterization-based CVP. Studies were screened for predefined inclusion criteria and rated for quality by duplicate observers. Standardized correlation coefficients for each ultrasound-based indicator were meta-analyzed using a random effects model.Results 3949 articles were screened and 64 met the criteria for inclusion. Inferior vena cava (IVC) diameter was assessed in 34 study measures and the pooled standardized correlation with invasive CVP was 0.74 (95% CI 0.63 to 0.84). IVC collapsibility was assessed in 20 study measures and the pooled standardized correlation with invasive CVP was -0.57 (95% CI -0.70 to -0.44). Tricuspid E/Ep was assessed in 6 study measures and the pooled standardized correlation with invasive CVP was 0.59 (95% CI 0.26 to 0.93). IVC parameters but not E/Ep remained correlated with CVP in mechanically ventilated patients, including cardiac surgery patients. Results were similar in studies featuring non-traditional users and cardiac specialists.Conclusions Echocardiographic IVC diameter, collapsibility, and tricuspid E/Ep ratio are significantly correlated with invasive CVP, albeit with important heterogeneity between studies. Most of these indicators are equally valid when applied in ventilated patients and by non-traditional users.

BACKGROUND Inpatients are often prescribed cardiopulmonary resuscitation (CPR) without a shared decision-making process. Since implementation of decision aids into practice is highly sensitive to the clinical milieu, we performed a pilot study to refine our study procedures and to evaluate the acceptability and potential effectiveness of a shared decision-making intervention when implemented in a Canadian hospital setting. METHODS In this before-after pilot study, we recruited patients and family members on the medical wards of 2 Canadian teaching hospitals between September 2015 and March 2017. The intervention consisted of viewing a CPR decision video and completing a values-clarification worksheet; follow-up discussion with the physician was encouraged. The primary feasibility outcome was acceptability of the video, and the primary effectiveness outcome was change in the Decisional Conflict Scale score (lower scores being more desirable) after the intervention. Participants rated the extent of shared decision-making using the CollaboRATE instrument. RESULTS Of the 71 participants (43 patients with a mean age of 79.0 [standard deviation (SD) 11.4] yr and 28 family members with a mean age of 61.0 [SD 10.0] yr), 65 (92%) rated the CPR decision video as good to excellent. The intervention was associated with an improvement in knowledge about CPR (+2.7 points, 95% confidence interval [CI] 2.2 to 3.3, effect size 1.5) and a reduction in the Decisional Conflict Scale score (-18.1 points, 95% CI -21.8 to -14.3, effect size 1.4). The 36 participants who had a discussion with a physician about CPR after watching the video rated the extent of shared decision-making as 6.3 (SD 1.7) (possible maximum score 9). There was a nonsignificant decrease in the proportion of patients with a medical order for CPR after the intervention (71% before v. 63% after, p = 0.06). INTERPRETATION The CPR decision video was acceptable to patients and family members. Our decision-support intervention may improve knowledge, reduce decisional conflict and reduce the prevalence of medical orders for CPR in the Canadian hospital setting.

Purpose Bioelectrical impedance analysis (BIA) is a technology that provides a rapid, non-invasive measurement of volume in body compartments and may aid the physician in the assessment of volume status. We sought to investigate the effect of BIA-measured volume status on duration of mechanical ventilation, 28-day mortality, and acute kidney injury requiring renal replacement therapy in a population of medical/surgical patients admitted to the intensive care unit (ICU). Methods Prospective observational study of adult patients who required mechanical ventilation within 24 hr of admission to ICU. Bioelectrical impedance analysis measured extracellular water (ECW) and total body water (TBW) and these measurements were recorded on days 1, 3, 5, and 7. Results A total of 36 patients were enrolled. Mean (standard deviation) age was 61.8 (21.3) years and 31% of patients were female. The majority were admitted from the emergency department or operating room. The most common diagnosis was sepsis. At 28 days, eight patients (22%) had died. There was no association between ECW/TBW ratio at day 1 and 28-day mortality (odds ratio, 1.2; 95% confidence interval [CI], 0.6 to 2.3) after adjusting for age, sex, and Acute Physiology and Chronic Health Evaluation II score. The median [interquartile range] number of ventilator days was 5 [2.5-7.5]. On day 1, for each 1% increase in the ECW/TBW ratio, there was a 1.2-fold increase in ventilator days (95% CI, 1.003 to 1.4; P = 0.05). It is notable that 20% of eligible patients could not be enrolled because medical equipment interfered with correct electrode placement. Conclusion Bioimpedance-measured ECW/TBW on day 1 of admission to the ICU is associated with time on the ventilator. While this technology may be a useful adjunct to the clinical assessment of volume status, there are technical barriers to its routine use in a general ICU population.

We report that air medical transportation of patients supported by mechanical circulatory support devices is safe. Complications can be mitigated by training and addressed either during the predeparture or in-transportation phase.

Introduction The most recent Global Initiative for Chronic Obstructive Lung Disease consensus recommends a 5-day course of corticosteroid (CS) therapy for acute chronic obstructive pulmonary disease exacerbations (ACOPDE). As inappropriate use of CS therapy is associated with adverse events, we implemented a peer-to-peer education intervention to improve adherence to guidelines for patients with ACOPDE admitted to a medical clinical teaching unit at a tertiary care university centre. Methods Our study was a before–after design study with a concurrent control of a 15 min peer-to-peer educational intervention targeting medical residents at the beginning of a 4-week rotation for 12 consecutive months. Another medical teaching unit within the same university network, but at a different site, served as a concurrent control. The primary outcome was the proportion of patients who received appropriate duration of CS therapy (5 days) for ACOPDE during the intervention period as compared with the 12-month preintervention period at the intervention and control hospitals. Results Following the intervention, there was an increase in the proportion of patients receiving appropriate duration of CS therapy (34.2% to 51.3%, p=0.02) at the intervention hospital and no significant difference at the control hospital (22.8% to 34.1%, p=0.15). This effect was maintained at the intervention hospital 3 months postintervention period. Conclusion A short peer-to-peer educational intervention targeting medical residents on a clinical teaching unit improved adherence to appropriate duration of CS therapy for ACOPDE.

Objective: Early mobilization is safe, feasible, and associated with better outcomes in patients with critical illness. However, barriers to mobilization in clinical practice still exist. The objective of this study was to assess the knowledge and practice patterns of intensive care unit (ICU) clinicians, as well as the barriers and facilitators to early mobilization. Design: Cross-sectional survey. Setting: Intensive care units of 3 university-affiliated hospitals in Montreal, Canada. Participants: One hundred and thirty-eight ICU clinicians, including nurses, physicians, respiratory therapists, and physiotherapists. Interventions: None. Measurements: Perceived barriers, facilitators, knowledge, and practice patterns of early mobilization were assessed using a previously validated mobility survey tool. Main Results: The overall response rate was 50.0% (138 of 274). Early mobilization was not perceived as a top priority in 49% of respondents. Results showed that clinicians were not fully aware of the benefits of early mobilization as per the current literature. About 58% of clinicians did not feel well trained and informed to mobilize mechanically ventilated patients. Perceptions on patient-level barriers varied with clinicians’ professional training, but there was a high degree of interprofessional and intraprofessional disagreement on the permissible maximal level activity in different scenarios of critically ill patients. Conclusions: Our survey shows limited awareness, among our respondents, of the clinical benefits of early mobilization and high level of disagreement on the permissible maximal level of activity in the critically ill patients. Future studies should evaluate the role of knowledge translation in modifying these barriers and improving early mobilization.

Background: Management of congestive heart failure (CHF) is dependent on clinical assessments of volume status, which are subjective and imprecise. Point-of-care ultrasound (POCUS) is useful in the diagnosis of CHF, but how POCUS findings correlate with therapy remains unknown. This study aimed to determine whether the changes in clinical evaluation of CHF with treatment are mirrored with changes in the number of B lines on lung ultrasound (LUS) and inferior vena cava (IVC) size. In this prospective observational study, investigators performed serial clinical and ultrasound assessments within 24 h of admission (T1), day 1 in hospital (T2) and within 24 h of discharge (T3). Clinical assessments included an evaluation of the jugular venous distension (JVD), hepatojugular reflux (HJR), pulmonary rales and a clinical congestion score was calculated. Ultrasound assessment included the IVC size and collapsibility, and the number of B lines in an 8-point scan.Results: Fifty consecutive patients were recruited with a mean age of 71.2 years (SD 12.7). Mean clinical congestion score on admission was 5.6 (SD 1.4) and declined significantly over time to 1.3 (0.91), as did the JVP, HJR and pulmonary rales. No significant changes were found in the IVC size between T1 [1.9 (0.65)] and T3 [2.0 (0.50)] or in the IVC collapsibility index [T1 0.3 (0.19) versus T3 0.25 (0.16)]. The mean number of B lines decreased from 11 (6.1) at T1 to 8.3 (5.5) at T3, although this decrease did not reach statistical significance. Spearman correlation between JVP and HJR versus IVC collapsibility and total B lines did not yield significant results.Conclusions: Clinical exam findings correlate over time during the management of CHF, whereas LUS and IVC results did not. The number of B lines did decrease with therapy, but did not reach statistical significance likely because the sampled population was small and had only mild heart failure. Further studies are warranted to further explore the use of lung ultrasound in this patient population.

Opioids and benzodiazepines are frequently used in the intensive care unit (ICU). Regular use and prolonged exposure to opioids in ICU patients followed by abrupt tapering or cessation may lead to iatrogenic withdrawal syndrome (IWS). IWS is well described in pediatrics, but no prospective study has evaluated this syndrome in adult ICU patients. The objective of this study was to determine the incidence of IWS caused by opioids in a critically ill adult population. This multicenter prospective cohort study was conducted at two level-1 trauma ICUs between February 2015 and September 2015 and included 54 critically ill patients. Participants were eligible if they were 18 years and older, mechanically ventilated and had received more than 72 h of regular intermittent or continuous intravenous infusion of opioids. For each enrolled patient and per each opioid weaning episode, presence of IWS was assessed by a qualified ICU physician or senior resident according to the 5th edition of Diagnostic and Statistical Manual of Mental Disorders criteria for opioid withdrawal.

BACKGROUND:Adverse events (AEs) in acute care hospitals are frequent and associated with significant morbidity, mortality, and costs. Measuring AEs is necessary for quality improvement and benchmarking purposes, but current detection methods lack in accuracy, efficiency, and generalizability. The growing availability of electronic health records (EHR) and the development of natural language processing techniques for encoding narrative data offer an opportunity to develop potentially better methods. The purpose of this study is to determine the accuracy and generalizability of using automated methods for detecting three high-incidence and high-impact AEs from EHR data: a) hospital-acquired pneumonia, b) ventilator-associated event and, c) central line-associated bloodstream infection.METHODS:This validation study will be conducted among medical, surgical and ICU patients admitted between 2013 and 2016 to the Centre hospitalier universitaire de Sherbrooke (CHUS) and the McGill University Health Centre (MUHC), which has both French and English sites. A random 60% sample of CHUS patients will be used for model development purposes (cohort 1, development set). Using a random sample of these patients, a reference standard assessment of their medical chart will be performed. Multivariate logistic regression and the area under the curve (AUC) will be employed to iteratively develop and optimize three automated AE detection models (i.e., one per AE of interest) using EHR data from the CHUS. These models will then be validated on a random sample of the remaining 40% of CHUS patients (cohort 1, internal validation set) using chart review to assess accuracy. The most accurate models developed and validated at the CHUS will then be applied to EHR data from a random sample of patients admitted to the MUHC French site (cohort 2) and English site (cohort 3)-a critical requirement given the use of narrative data -, and accuracy will be assessed using chart review. Generalizability will be determined by comparing AUCs from cohorts 2 and 3 to those from cohort 1.DISCUSSION:This study will likely produce more accurate and efficient measures of AEs. These measures could be used to assess the incidence rates of AEs, evaluate the success of preventive interventions, or benchmark performance across hospitals.