A Canadian survey of perceptions and practices related to ordering of blood tests in the intensive care unit.

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.

RéSUMé: OBJECTIF: La prescription à l'avance de tests sanguins de routine est courante dans les unités de soins intensifs (USI), avec une prise en compte limitée de la probabilité de découverte d'anomalies avant le test. Cette pratique contribue à l'anémie, aux résultats faussement positifs et aux coûts des soins de santé. Nous avons cherché à comprendre les pratiques et les attitudes des intensivistes pour adultes au Canada en ce qui concerne la prescription d'analyses sanguines chez la patientèle gravement malade. MéTHODE: Nous avons mené un sondage transversal à l'échelle nationale au Canada en posant 15 questions évaluant trois domaines (perceptions globales, commande de tests, pratique quotidienne), ainsi que 11 questions démographiques. L'échantillon cible était composé d'un·e intensiviste par unité de soins intensifs pour adultes au Canada. Nous avons résumé les réponses à l'aide de statistiques descriptives et présenté les données sous forme de moyennes avec écarts type (ET) ou de dénombrements avec pourcentages, selon le cas. RéSULTATS: Sur une période de sept mois, 80 médecins sur 131 (61%) ont répondu dans 77 unités de soins intensifs, dont 50% en Ontario. Les répondant·es avaient une expérience clinique moyenne (ET) de 12 (9) ans, et 61% travaillaient dans des centres universitaires. Lorsqu'on leur a demandé ce qu'ils ou elles pensaient de la fréquence à laquelle des tests sanguins inutiles étaient prescrits, 61% ont répondu « parfois ¼ et 23% ont répondu « presque toujours ¼. Cinquante-sept pour cent étaient en faveur de la réalisation d'une formule sanguine complète un jour à l'avance. Seulement 24% des personnes interrogées estimaient que la prescription de tests sanguins à l'avance entraînait fréquemment des changements dans la prise en charge. Les facteurs les plus souvent perçus comme influençant la prescription d'analyses sanguines à l'unité de soins intensifs étaient les préférences des médecins, les habitudes institutionnelles et les ensembles d'ordonnances. CONCLUSION: La plupart des répondant·es à ce sondage ont l'impression que des tests sanguins inutiles sont prescrits aux soins intensifs. L'enquête a permis d'identifier des stratégies possibles pour réduire le nombre de tests sanguins.

Mental Disorders Among Mothers of Children Born Preterm: A Population-Based Cohort Study in Canada.

BACKGROUND: Our aim was to examine the association between preterm delivery and incident maternal mental disorders using a population-based cohort of mothers in Canada. METHODS: Retrospective matched cohort study using Manitoba Centre for Health Policy (MCHP) administrative data in Manitoba. Mothers who delivered preterm babies (<37 weeks gestational age) between 1998 and 2013 were matched 1:5 to mothers of term babies using socio-demographic variables. Primary outcome was any incident mental disorder within 5 years of delivery defined as any of (a) mood and anxiety disorders, (b) psychotic disorders, (c) substance use disorders, and (d) suicide or suicide attempts. Multivariable Poisson regression model was used to estimate the 5-year adjusted incidence rate ratios (IRRs). RESULTS: Mothers of preterm children (N = 5,361) had similar incidence rates of any mental disorder (17.4% vs. 16.6%, IRR = 0.99, 95% CI, 0.91 to 1.07) compared to mothers of term children (N = 24,932). Mothers of term children had a higher rate of any mental disorder in the first year while mothers of preterm children had higher rates from 2 to 5 years. Being the mother of a child born <28 week (IRR = 1.5, 95% CI, 1.14 to 2.04), but not 28-33 weeks (IRR = 1.03, 95% CI, 0.86 to 1.19) or 34-36 weeks (IRR = 0.96, 95% CI, 0.88 to 1.05), was associated with any mental disorder. INTERPRETATION: Mothers of preterm and term children had similar rates of incident mental disorders within 5-years post-delivery. Extreme prematurity was a risk factor for any mental disorder. Targeted screening and support of this latter group may be beneficial.

Effect of Air Transport Delay on Mortality in Critical Illness: A Population-Based Cohort Study.

OBJECTIVE: For critically ill patients in remote areas, we assessed the association of transport delay via fixed wing air ambulance on 30-day mortality, excluding interhospital transports. METHODS: This was a retrospective cohort analysis of all such adult transports in Manitoba, Canada, over 5.4 years. Causal mediation analysis was used, with the Acute Physiology and Chronic Health Evaluation II Acute Physiology Score at the destination intensive care unit as the mediator. The covariates were age, sex, comorbidities, socioeconomic status, and physiologic variables from the sending site. RESULTS: The primary cohort was composed of 554 patients; 113 (20.4%) died within 30 days. The total transport delay (mean ± standard deviation) was 5.1 ± 1.7 hours. Compared with no delay, the average 5-hour transport delay was associated with an odds ratio for mortality of 1.34 with a 95% confidence interval from 40% lower to 270% higher, with 60% of the influence of total travel time attributable to worsening of patients' acute physiologic status during the delay in intensive care unit admission due to transport. CONCLUSIONS: Although these findings provide insufficient evidence for an effect of fixed wing air transport delay on mortality among critically ill patients, they underscore the need for additional and larger studies on this topic.

Variation in Bed-to-Physician Ratios During Weekday Daytime Hours in ICUs in Australia and New Zealand.

OBJECTIVES: To determine common "bed-to-physician" ratios during weekday hours across ICUs and assess factors associated with variability in this ratio. DESIGN: Retrospective cohort study. SETTING: All ICUs in Australia/New Zealand that participated in a staffing survey administered in 2017-2018. PATIENTS: ICU admissions from 2016 to 2018. METHODS: We linked survey data with patient-level data. We defined: 1) bed-to-intensivist ratio as the number of usually available ICU beds divided by the number of onsite weekday daytime intensivists; and 2) bed-to-physician ratio as the number of available ICU beds divided by the total number of physicians (intensivists + nonintensivists, including trainees). We calculated the median and interquartile range (IQR) of bed-to-intensivist ratio and bed-to-physician ratios during weekday hours. We assessed variability in each by type of hospital and ICU and by severity of illness of patients, defined by the predicted hospital mortality. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 123 (87.2%) of Australia/New Zealand ICUs that returned staffing surveys, 114 (92.7%) had an intensivist present during weekday daytime hours, and 116 (94.3%) reported at least one nonintensivist physician. The median bed-to-intensivist ratio was 8.0 (IQR, 6.0-11.4), which decreased to a bed-to-physician ratio of 3.0 (IQR, 2.2-4.9). These ratios varied with mean severity of illness of the patients in the unit. The median bed-to-intensivist ratio was highest (13.5) for ICUs with a mean predicted mortality > 2-4%, and the median bed-to-physician ratio was highest (5.7) for ICUs with a mean predicted mortality of > 4-6%. Both ratios decreased and plateaued in ICUs with a mean predicted mortality for patients greater than 8% (median bed-to-intensivist ratio range, 6.8-8.0, and bed-to-physician ratio range of 2.4-2.7). CONCLUSIONS: Weekday bed-to-physician ratios in Australia/New Zealand ICUs are lower than the bed-to-intensivist ratios and have a relatively fixed ratio of less than 3 for units taking care of patients with a higher average severity of illness. These relationships may be different in other countries or healthcare systems.

BABEL (Better tArgeting, Better outcomes for frail ELderly patients) advance care planning: a comprehensive approach to advance care planning in nursing homes: a cluster randomised trial.

BACKGROUND: Nursing home (NH) residents should have the opportunity to consider, discuss and document their healthcare wishes. However, such advance care planning (ACP) is frequently suboptimal. OBJECTIVE: Assess a comprehensive, person-centred ACP approach. DESIGN: Unblinded, cluster randomised trial. SETTING: Fourteen control and 15 intervention NHs in three Canadian provinces, 2018-2020. SUBJECTS: 713 residents (442 control, 271 intervention) aged ≥65 years, with elevated mortality risk. METHODS: The intervention was a structured, $\sim$60-min discussion between a resident, substitute decision-maker (SDM) and nursing home staff to: (i) confirm SDMs' identities and role; (ii) prepare SDMs for medical emergencies; (iii) explain residents' clinical condition and prognosis; (iv) ascertain residents' preferred philosophy to guide decision-making and (v) identify residents' preferred options for specific medical emergencies. Control NHs continued their usual ACP processes. Co-primary outcomes were: (a) comprehensiveness of advance care planning, assessed using the Audit of Advance Care Planning, and (b) Comfort Assessment in Dying. Ten secondary outcomes were assessed. P-values were adjusted for all 12 outcomes using the false discovery rate method. RESULTS: The intervention resulted in 5.21-fold higher odds of respondents rating ACP comprehensiveness as being better (95% confidence interval [CI] 3.53, 7.61). Comfort in dying did not differ (difference = -0.61; 95% CI -2.2, 1.0). Among the secondary outcomes, antimicrobial use was significantly lower in intervention homes (rate ratio = 0.79, 95% CI 0.66, 0.94). CONCLUSIONS: Superior comprehensiveness of the BABEL approach to ACP underscores the importance of allowing adequate time to address all important aspects of ACP and may reduce unwanted interventions towards the end of life.

White blood cell count trajectory and mortality in septic shock: a historical cohort study.

PURPOSE: Septic shock is associated with a mortality of 20-40%. The white blood cell count (WBC) at hospital admission correlates with prognosis in septic shock. Here, we explore whether the trajectory of WBC after admission provides further information about outcomes. We aimed to identify groups of patients with different WBC trajectories and the association of WBC trajectory with mortality. METHODS: We included adult patients with septic shock in two academic intensive care units (ICU) in Winnipeg, MB, Canada between 2006 and 2012. We used group-based trajectory analysis to group patients according to their WBC patterns over the first seven days in the ICU. Our primary analysis was the association of WBC trajectory group on 30-day mortality using multivariable Cox proportional hazards regression. RESULTS: We included 917 patients with septic shock. The final model identified seven distinct WBC trajectories. The rising WBC trajectory was independently associated with increased mortality (hazard ratio, 3.41; 95% confidence interval, 1.86 to 6.26; P < 0.001) compared with the stable WBC trajectory. CONCLUSION: In patients with septic shock, distinct and clinically relevant groups can be identified by analyzing WBC trajectories. A rising WBC trajectory was associated with higher mortality.

RéSUMé: OBJECTIF: Le choc septique est associé à une mortalité de 20 à 40 %. La numération leucocytaire à l'admission à l'hôpital est corrélée au pronostic en cas de choc septique. Dans ce manuscrit, nous tentons de déterminer si l'évolution de la numération leucocytaire après l'admission fournit plus d'informations sur les devenirs. Nous avons cherché à identifier des groupes de patients présentant différentes trajectoires d'évolution de numération leucocytaire et l'association entre l'évolution de la numération et la mortalité. MéTHODE: Nous avons inclus des patients adultes atteints d'un choc septique dans deux unités de soins intensifs (USI) universitaires à Winnipeg, Manitoba, Canada entre 2006 et 2012. Nous avons utilisé une analyse de l'évolution basée sur le groupe pour regrouper les patients en fonction du type d'évolution de la numération leucocytaire au cours des sept premiers jours à l'USI. Notre analyse principale consistait à déterminer l'association entre le groupe d'évolution de numération leucocytaire et la mortalité à 30 jours en utilisant une régression multivariable à risque proportionnel de Cox. RéSULTATS: Nous avons inclus 917 patients atteints de choc septique. Le modèle final a identifié sept types de trajectoire d'évolution de numération leucocytaire distincts. Une évolution ascendante de la numération leucocytaire était indépendamment associée à une augmentation de la mortalité (rapport de risque, 3,41; intervalle de confiance à 95 %, 1,86 à 6,26; P < 0,001) par rapport à une évolution de numération leucocytaire stable. CONCLUSION: Chez les patients atteints de choc septique, des groupes distincts et cliniquement pertinents peuvent être identifiés en analysant les trajectoires d'évolution de la numération leucocytaire. Une évolution ascendante de la numération leucocytaire était associée à une mortalité plus élevée.

Prophylactic tranexamic acid use in non-cardiac surgeries at high risk for transfusion.

BACKGROUND: Tranexamic acid (TXA) reduces transfusion in a wide range of surgical populations, although its real-world use in non-cardiac surgeries has not been well described. The objective of this study was to describe prophylactic TXA use in non-cardiac surgeries at high risk for transfusion. METHODS: This is a retrospective cohort study of all adult patients undergoing major non-cardiac surgery at ≥5% risk of perioperative transfusion at five Canadian hospitals between January 2014 and December 2016. Canadian Classification of Health Interventions procedure codes within the Discharge Abstract Database were linked to transfusion and laboratory databases. TXA use was ascertained electronically from The Ottawa Hospital Data Warehouse and via manual chart review for Winnipeg hospitals. For each surgery, we evaluated the percentage of patients who received TXA as well as the specifics of TXA dosing and administration. RESULTS: TXA use was evaluable in 14 300 patients. Overall, 17% of surgeries received TXA, ranging from 0% to 68% among individual surgeries. TXA use was more common in orthopaedic (n = 2043/4942; 41%) and spine surgeries (n = 239/1322; 18%) compared to other surgical domains (n = 109/8036; 1%). TXA was commonly administered as a bolus (n = 2097/2391; 88%). The median TXA dose was 1000 mg (IQR 1000-1000 mg). CONCLUSION: TXA is predominantly used in orthopaedic and spine surgeries, with little uptake in other non-cardiac surgeries at high risk for red blood cell transfusion. Further studies are needed to evaluate the effectiveness and safety of TXA and to understand the barriers to TXA administration in a broad range of non-cardiac surgeries.

Epidemiology of intravenous immune globulin in septic shock: a retrospective cohort analysis of the Premier Healthcare Database.

PURPOSE: Intravenous immune globulin (IVIG) may improve survival in people with septic shock. Current utilization patterns of IVIG are unknown. We sought to characterize adult patients with septic shock requiring vasopressors who received IVIG, describes IVIG regimens, and evaluate determinants of IVIG use in patients with septic shock. METHODS: We conducted a retrospective database study of adult patients with septic shock admitted to US hospitals in the Premier Healthcare Database (from July 2010 to June 2013). We described the proportion of patients with septic shock receiving IVIG, examined IVIG regimens across sites and employed random-effects multivariable regression techniques to identify predictors of IVIG use. RESULTS: Intravenous immune globulin was administered to 0.3% (n = 685) of patients with septic shock; with a median [interquartile range (IQR)] dose of 1 [0.5-1.8] g·kg-1 for a median [IQR] of 1 [1-2] day. Receipt of IVIG was less likely for Black patients (odds ratio [OR], 0.54; 95% confidence interval [CI] 0.41 to 0.72) and patients without private insurance (Medicare OR, 0.73; 95% CI 0.59 to 0.90; Medicaid OR, 0.41; 95% CI 0.30 to 0.57) and more likely for patients with immunocompromise (OR, 6.83; 95% CI 5.47 to 8.53), necrotizing fasciitis (OR, 9.78; 95% CI 6.97 to 13.72), and toxic shock (OR, 56.9; 95% CI 38.7 to 83.7). CONCLUSIONS: Intravenous immune globulin is used infrequently across the US in patients with septic shock. Regimens of IVIG in septic shock may be less intensive than those associated with a survival benefit in meta-analyses. Observed infrequent use supports apparent clinical equipoise, perhaps secondary to limitations of the primary literature. A clinical trial evaluating the role of IVIG in septic shock is needed.

RéSUMé: OBJECTIF: L'immunoglobuline intraveineuse (IGIV) peut améliorer la survie chez les personnes atteintes de choc septique. Les pratiques actuelles d'utilisation de l'IGIV sont inconnues. Nous avons cherché à caractériser les patients adultes en état de choc septique et nécessitant des vasopresseurs qui ont reçu de l'IGIV, à décrire les dosages administrés d'IGIV, et à évaluer les causes déterminantes d'une utilisation d'IGIV chez ces patients. MéTHODE: Nous avons réalisé une étude rétrospective de base de données portant sur des patients adultes atteints de choc septique admis dans des hôpitaux américains et inclus dans la base de données Premier Healthcare (de juillet 2010 à juin 2013). Nous avons décrit la proportion de patients en choc septique recevant de l'IGIV, examiné les posologies utilisées d'IGIV à travers les sites et employé des techniques de régression multivariable à effets aléatoires pour identifier les prédicteurs de l'utilisation d'IGIV. RéSULTATS: L'IGIV a été administrée à 0,3 % (n = 685) des patients présentant un choc septique, avec une dose médiane [écart interquartile (ÉIQ)] de 1 [0,5­1,8] g·kg-1 pour une médiane [ÉIQ] de 1 [1­2] jour. L'administration d'IGIV était moins probable chez les patients noirs (rapport de cotes [RC], 0,54; intervalle de confiance [IC] à 95 %, 0,41 à 0,72) et les patients sans assurance privée (RC Medicare, 0,73; IC 95 %, 0,59 à 0,90; RC Medicaid, 0,41; IC 95 %, 0,30 à 0,57) et plus probable chez les patients immunodéprimés (RC, 6,83; IC 95 %, 5,47 à 8,53), atteints de fasciite nécrosante (RC, 9,78; IC 95 %, 6,97 à 13,72), et en choc toxique (RC, 56,9; IC 95 %, 38,7 à 83,7). CONCLUSION: L'IGIV est rarement utilisée aux États-Unis chez les patients en choc septique. Les dosages d'IGIV utilisés en cas de choc septique pourraient être moins intensifs que ceux associés à un effet bénéfique en matière de survie dans les méta-analyses. L'utilisation peu fréquente observée appuie une équivalence clinique apparente, peut-être secondaire aux limites de la littérature princeps. Une étude clinique évaluant le rôle de l'IGIV dans le choc septique est nécessaire.

Intravenous immune globulin in septic shock: a Canadian national survey of critical care medicine and infectious disease specialist physicians.

PURPOSE: This national survey evaluated the perceived efficacy and safety of intravenous immune globulin (IVIG) in septic shock, self-reported utilization patterns, barriers to use, the population of interest for further trials and willingness to participate in future research of IVIG in septic shock. METHODS: We conducted a cross-sectional survey of critical care and infectious diseases physicians across Canada. We summarized categorical item responses as counts and proportions. We developed a multivariable logistic regression model to identify physician-level predictors of IVIG use in septic shock. RESULTS: Our survey was disseminated to 674 eligible respondents with a final response rate of 60%. Most (91%) respondents reported having prescribed IVIG to patients with septic shock at least once, 86% for septic shock due to necrotizing fasciitis, 52% for other bacterial toxin-mediated causes of septic shock, and 5% for undifferentiated septic shock. The majority of respondents expressed uncertainty regarding the impact of IVIG on mortality (97%) and safety (95%) in septic shock. Respondents were willing to participate in further IVIG research with 98% stating they would consider enrolling their patients into a trial of IVIG in septic shock. Familiarity with published evidence was the single greatest predictor of IVIG use in septic shock (odds ratio, 10.2; 95% confidence interval, 3.4 to 30.5; P < 0.001). CONCLUSIONS: Most Canadian critical care and infectious diseases specialist physicians reported previous experience using IVIG in septic shock. Respondents identified inadequacy of existing research as the greatest barrier to routine use of IVIG in septic shock. Most respondents support the need for further studies on IVIG in septic shock, and would consider enrolling their own patients into a trial of IVIG in septic shock.

RéSUMé: OBJECTIF : Cette enquête nationale a évalué l'efficacité et l'innocuité perçues des immunoglobulines intraveineuses (IgIV) dans le contexte du choc septique, les habitudes d'utilisation autodéclarées, les obstacles à l'utilisation de cette modalité, les populations à explorer pour des études futures et la volonté de participer aux recherches futures sur les IgIV et le choc septique. MéTHODE : Nous avons mené une enquête transversale auprès de médecins intensivistes et spécialistes des maladies infectieuses au Canada. Nous avons résumé les réponses de chaque point catégorique en tant que dénombrement et proportions. Nous avons mis au point un modèle de régression logistique multivariée afin d'identifier les prédicteurs, au niveau des médecins, d'une utilisation des IgIV en cas de choc septique. RéSULTATS : Notre sondage a été acheminé à 674 médecins admissibles et nous avons obtenu un taux de réponse final de 60 %. La plupart (91%) des répondants ont indiqué avoir prescrit des IgIV aux patients en choc septique au moins une fois, 86 % pour un choc septique dû à une fasciite nécrosante, 52 % pour des chocs septiques d'autres étiologies médiées par des toxines bactériennes, et 5 % dans des cas de choc septique non différencié. La majorité des répondants ont exprimé de l'incertitude quant à l'incidence des IgIV sur la mortalité (97 %) et l'innocuité (95 %) lors de choc septique. Les répondants étaient disposés à participer à d'autres recherches sur les IgIV, 98 % déclarant qu'ils envisageraient d'inscrire leurs patients à une étude sur les IgIV et le choc septique. La familiarité avec les données probantes publiées était le plus grand prédicteur d'utilisation d'IgIV dans un contexte de choc septique (rapport de cotes, 10,2; intervalle de confiance à 95 %, 3,4 à 30,5; P < 0,001). CONCLUSION : La plupart des médecins intensivistes et spécialistes des maladies infectieuses canadiens ont rapporté avoir une expérience antérieure d'utilisation d'IgIV en cas de choc septique. Les répondants ont identifié l'insuffisance de la recherche existante comme le plus grand obstacle à l'utilisation systématique d'IgIV dans les cas de choc septique. La plupart des répondants appuient la nécessité d'études plus approfondies sur les IgIV et le choc septique et envisageraient d'inscrire leurs propres patients à une étude sur les IgIV dans un contexte de choc septique.

Variation in prophylactic tranexamic acid administration among anesthesiologists and surgeons in orthopedic surgery: a retrospective cohort study.

PURPOSE: Tranexamic acid (TXA) reduces red blood cell transfusion in various orthopedic surgeries, yet the degree of practice variation in its use among anesthesiologists and surgeons has not been described. To target future knowledge transfer and implementation strategies, and to better understand determinants of variability in prophylactic TXA use, our primary objective was to evaluate the influence of surgical team members on the variability of prophylactic TXA administration. METHODS: This was a retrospective cohort study of all adult patients undergoing primary total hip arthroplasty (THA), hip fracture surgery, and spine fusion ± vertebrectomy at two Canadian hospitals between January 2014 and December 2016. We used Canadian Classification of Health Interventions procedure codes within the Discharge Abstract Database which we linked to the Ottawa Data Warehouse. We described the percentage of patients that received TXA by individual surgery, the specifics of TXA dosing, and estimated the effect of anesthesiologists and surgeons on prophylactic TXA using multivariable mixed-effects logistic regression analyses. RESULTS: In the 3,900 patients studied, TXA was most commonly used in primary THA (85%; n = 1,344/1,582), with lower use in hip fracture (23%; n = 342/1,506) and spine fusion surgery (23%; n = 186/812). The median [interquartile range] total TXA dose was 1,000 [1,000-1,000] mg, given as a bolus in 92% of cases. Anesthesiologists and surgeons added significant variability to the odds of receiving TXA in hip fracture surgery and spine fusion, but not primary THA. Most of the variability in TXA use was attributed to patient and other factors. CONCLUSION: We confirmed the routine use of TXA in primary THA, while observing lower utilization with more variability in hip fracture and spine fusion surgery. Further study is warranted to understand variations in use and the barriers to TXA implementation in a broader population of orthopedic surgical patients at high risk for transfusion.

RéSUMé: OBJECTIF: L'acide tranexamique (ATX) réduit la transfusion d'érythrocytes dans diverses chirurgies orthopédiques. Cependant, les variations de pratique quant à son utilisation parmi les anesthésiologistes et les chirurgiens n'ont pas été décrites. Afin de cibler les stratégies futures de transfert des connaissances et de mise en œuvre, et pour mieux comprendre les déterminants de la variabilité dans l'utilisation prophylactique d'ATX, notre objectif principal était d'évaluer l'influence des membres de l'équipe chirurgicale sur la variabilité de l'administration prophylactique d'ATX. MéTHODE: Il s'agissait d'une étude de cohorte rétrospective de tous les patients adultes subissant une arthroplastie totale primaire de la hanche (ATH), une chirurgie de fracture de la hanche et une fusion intervertébrale ± vertébrectomie dans deux hôpitaux canadiens entre janvier 2014 et décembre 2016. Nous avons utilisé les codes de procédure de la Classification canadienne des interventions en santé dans la Base de données sur les congés des patients, que nous avons liée à la banque de données d'Ottawa. Nous avons décrit le pourcentage de patients qui ont reçu de l'ATX par chirurgie individuelle, les détails du dosage de l'ATX, et avons estimé l'effet des anesthésiologistes et des chirurgiens sur l'ATX prophylactique en réalisant des analyses de régression logistique multivariées à effets mixtes. RéSULTATS: Parmi les 3900 patients étudiés, l'ATX était le plus fréquemment utilisé lors d'une ATH primaire (85 %; n = 1344/1582), avec une utilisation plus faible lors de chirurgie de fracture de la hanche (23 %; n = 342/1506) et de chirurgie de fusion intervertébrale (23 %; n = 186/812). La dose totale médiane [écart interquartile] d'ATX était de 1000 mg [1000 à 1000], administrés dans 92 % des cas sous forme de bolus. Les anesthésiologistes et les chirurgiens ont ajouté une variabilité significative aux probabilités de recevoir de l'ATX lors d'une chirurgie de fracture de la hanche et de fusion, mais pas lors d'ATH primaire. La majeure partie de la variabilité dans l'utilisation d'ATX était attribuable aux facteurs liés au patient et à d'autres facteurs. CONCLUSION: Nous avons confirmé l'utilisation de routine de l'ATX dans l'ATH primaire, tout en observant une utilisation moins répandue et plus variable lors de chirurgie de fracture de la hanche et de fusion intervertébrale. Une étude plus approfondie est nécessaire pour comprendre les variations d'utilisation et les obstacles à la mise en œuvre de l'ATX dans une population plus étendue de patients de chirurgie orthopédique à haut risque de transfusion.

Association Between Consecutive Days Worked by Intensivists and Outcomes for Critically Ill Patients.

OBJECTIVE: To evaluate the association between consecutive days worked by intensivists and ICU patient outcomes. DESIGN: Retrospective cohort study linked with survey data. SETTING: Australia and New Zealand ICUs. PATIENTS: Adults (16+ yr old) admitted to ICU in the Australia New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Registries (July 1, 2016, to June 30, 2018). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We linked data on staffing schedules for each unit from the Critical Care Resources Registry 2016-2017 annual survey with patient-level data from the Adult Patient Database. The a priori chosen primary outcome was ICU length of stay. Secondary outcomes included hospital length of stay, ICU readmissions, and mortality (ICU and hospital). We used multilevel multivariable regression modeling to assess the association between days of consecutive intensivist service and patient outcomes; the predicted probability of death was included as a covariate and individual ICU as a random effect. The cohort included 225,034 patients in 109 ICUs. Intensivists were scheduled for seven or more consecutive days in 43 (39.4%) ICUs; 27 (24.7%) scheduled intensivists for 5 days, 22 (20.1%) for 4 days, seven (6.4%) for 3 days, four (3.7%) for 2 days, and six (5.5%) for less than or equal to 1 day. Compared with care by intensivists working 7+ consecutive days (adjusted ICU length of stay = 2.85 d), care by an intensivist working 3 or fewer consecutive days was associated with shorter ICU length of stay (3 consecutive days: 0.46 d fewer, p = 0.010; 2 consecutive days: 0.77 d fewer, p < 0.001; ≤ 1 consecutive days: 0.68 d fewer, p < 0.001). Shorter schedules of consecutive intensivist days worked were also associated with trends toward shorter hospital length of stay without increases in ICU readmissions or hospital mortality. CONCLUSIONS: Care by intensivists working fewer consecutive days is associated with reduced ICU length of stay without negatively impacting mortality.

Promotion of Regular Oesophageal Motility to Prevent Regurgitation and Enhance Nutrition Intake in Long-Stay ICU Patients. A Multicenter, Phase II, Sham-Controlled, Randomized Trial: The PROPEL Study.

OBJECTIVES: To evaluate the effect of esophageal stimulation on nutritional adequacy in critically ill patients at risk for enteral feeding intolerance. DESIGN: A multicenter randomized sham-controlled clinical trial. SETTING: Twelve ICUs in Canada. PATIENTS: We included mechanically ventilated ICU patients who were given moderate-to-high doses of opioids and expected to remain alive and ventilated for an additional 48 hours and who were receiving enteral nutrition or expected to start imminently. INTERVENTIONS: Patients were randomly assigned 1:1 to esophageal stimulation via an esophageal stimulating catheter (E-Motion Tube; E-Motion Medical, Tel Aviv, Israel) or sham treatment. All patients were fed via these catheters using a standardized feeding protocol. MEASUREMENTS AND MAIN RESULTS: The co-primary outcomes were proportion of caloric and protein prescription received enterally over the initial 7 days following randomization. Among 159 patients randomized, the modified intention-to-treat analysis included 155 patients: 73 patients in the active treatment group and 82 in the sham treatment group. Over the 7-day study period, the percent of prescribed caloric intake (± SE) received by the enteral route was 64% ± 2 in the active group and 65% ± 2 in sham patients for calories (difference, -1; 95% CI, -8 to 6; p = 0.74). For protein, it was 57% ± 3 in the active group and 60% ± 3 in the sham group (difference, -3; 95% CI, -10 to 3; p = 0.30). Compared to the sham group, there were more serious adverse events reported in the active treatment group (13 vs 6; p = 0.053). Clinically important arrhythmias were detected by Holter monitoring in 36 out of 70 (51%) in the active group versus 22 out of 76 (29%) in the sham group (p = 0.006). CONCLUSIONS: Esophageal stimulation via a special feeding catheter did not improve nutritional adequacy and was associated with increase risk of harm in critically ill patients.

Effects of Cardiovascular Health Shocks on Spouses' Work and Earnings: A National Study.

BACKGROUND: Acute health shocks can reduce the ability to work and earn among working-age survivors. The full economic impact includes labor market effects on spouses/partners, but there is a knowledge gap in this area. OBJECTIVES: The objective of this study was to assess how 3 common health shocks, acute myocardial infarction, stroke, and cardiac arrest, influence work and earnings of spouses aged 35-61 years. RESEARCH DESIGN: This retrospective cohort study of case and control couples used population-based, linked Canadian income tax and hospitalization data from 2005 to 2013. SUBJECTS: Case couples comprised 1 partner aged 41-61 years who experienced a health shock in the index year and survived 3 years hence, and a working-age partner. Control couples were matched up to 5:1 on 12 characteristics, with neither experiencing the health shock of interest in the index year. MEASURES: Primary outcome was the change in spousal annual earnings between the year prior and 3 years after the event. Pre-to-post spousal income changes were categorized into 9 levels and compared between case spouses and control spouses by the Pearson χ test. RESULTS: There were 11,208 matched case couples for acute myocardial infarction, 622 for cardiac arrest, and 2288 for stroke. Overall, case and control spouses experienced similar distributional changes in preevent to postevent earning (all P≥0.27). Heterogeneity analysis indicated that spouses of more severe stroke sufferers ceased working at a higher rate than for control spouses. CONCLUSION: Beyond assessing average values, detailed analysis of changes in spousal earnings after common cardiovascular health shocks did not demonstrate effects attributable to those health shocks.

Disparities in management and outcomes of myocardial infarction in multiple sclerosis: A matched cohort study.

BACKGROUND: Although multiple sclerosis (MS) confers an elevated risk of acute myocardial infarction (AMI), little is known about how it influences management of AMI. METHODS: Using population-based administrative (health) data from two Canadian provinces, we conducted a retrospective matched cohort study. We identified people with MS who had an incident AMI, and up to five AMI controls without MS matched on age, sex, and region. We compared the likelihood of undergoing cardiac catheterization within 30 days of AMI, time to revascularization, use of recommended pharmacotherapy post-AMI, and mortality at 30 and 365 days post-AMI using multivariable regression models adjusting for potential confounders. We pooled findings across provinces using meta-analysis. RESULTS: We identified 559 MS cases and 2523 matched controls. In the matched cohort, the MS cohort was less likely to undergo cardiac catheterization within 30 days of admission (odds ratio (OR) = 0.61; 95% confidence interval (CI) = 0.49-0.77), revascularization (hazard ratio (HR) = 0.78; 95% CI = 0.69-0.88), or to fill a prescription for recommended therapy. Mortality risk was higher in the MS cohort than in the matched cohort at 30 and 365 days post-AMI. CONCLUSION: Rates of diagnostic and therapeutic care, and survival after AMI were lower in the MS population than in a matched population.

Data initiatives supporting critical care research and quality improvement in Canada: an environmental scan and narrative review.

PURPOSE: Collection and analysis of health data are crucial to achieving high-quality clinical care, research, and quality improvement. This review explores existing hospital, regional, provincial and national data platforms in Canada to identify gaps and barriers, and recommend improvements for data science. SOURCE: The Canadian Critical Care Trials Group and the Canadian Critical Care Translational Biology Group undertook an environmental survey using list-identified names and keywords in PubMed and the grey literature, from the Canadian context. Findings were grouped into sections, corresponding to geography, purpose, and patient sub-group initiatives, using a narrative qualitative approach. Emerging themes, impressions, and recommendations towards improving data initiatives were generated. PRINCIPAL FINDINGS: In Canada, the Canadian Institute for Health Information Discharge Abstract Database contains high-level clinical data on every adult and child discharged from acute care facilities; however, it does not contain data from Quebec, critical care-specific severity of illness risk-adjustment scores, physiologic data, or data pertaining to medication use. Provincially mandated critical care platforms in four provinces contain more granular data, and can be used to risk adjust and link to within-province data sets; however, no inter-provincial collaborative mechanism exists. There is very limited infrastructure to collect and link biological samples from critically ill patients nationally. Comprehensive international clinical data sets may inform future Canadian initiatives. CONCLUSION: Clinical and biological data collection among critically ill patients in Canada is not sufficiently coordinated, and lags behind other jurisdictions. An integrated and inclusive critical care data platform is a key clinical and scientific priority in Canada.

Estimating ICU Benefit: A Randomized Study of Physicians.

OBJECTIVES: The distinction between overuse and appropriate use of the ICU hinges on whether a patient would benefit from ICU care. We sought to test 1) whether physicians agree about which types of patients benefit from ICU care and 2) whether estimates of ICU benefit are influenced by factors unrelated to severity of illness. DESIGN: Randomized study. SETTING: Online vignettes. SUBJECTS: U.S. critical care physicians. INTERVENTIONS: Physicians were provided with eight vignettes of hypothetical patients. Each vignette had a single patient or hospital factor randomized across participants (four factors related and four unrelated to severity of illness). MEASUREMENTS AND MAIN RESULTS: The primary outcome was the estimate of ICU benefit, assessed with a 4-point Likert-type scale. In total, 1,223 of 8,792 physicians volunteered to participate (14% recruitment rate). Physician agreement of ICU benefit was poor (mean intraclass correlation coefficient for each vignette: 0.06; range: 0-0.18). There were no vignettes in which more than two thirds of physicians agreed about the extent to which a patient would benefit from ICU care. Increasing severity of illness resulted in greater estimated benefit of ICU care. Among factors unrelated to severity of illness, physicians felt ICU care was more beneficial when told one ICU bed was available than if ICU bed availability was unmentioned. Physicians felt ICU care was less beneficial when family was present than when family presence was unmentioned. The patient's age, but not race/ethnicity, also impacted estimates of ICU benefit. CONCLUSIONS: Estimates of ICU benefit are widely dissimilar and influenced by factors unrelated to severity of illness, potentially resulting in inconsistent allocation of ICU care.

Effects of cardiovascular and cerebrovascular health events on work and earnings: a population-based retrospective cohort study.

BACKGROUND: Survivors of acute health events can experience lasting reductions in functional status and quality of life, as well as reduced ability to work and earn income. We aimed to assess the effect of acute myocardial infarction (MI), cardiac arrest and stroke on work and earning among working-age people. METHODS: For this retrospective cohort study, we used the Canadian Hospitalization and Taxation Database, which contains linked hospital and income tax data, from 2005 to 2013 to perform difference-in-difference analyses. We matched patients admitted to hospital for acute MI, cardiac arrest or stroke with controls who were not admitted to hospital for these indications. Participants were aged 40-61 years, worked in the 2 years before the event and were alive 3 years after the event. Patients were matched to controls for 11 variables. The primary outcome was working status 3 years postevent. We also assessed earnings change attributable to the event. We matched 19 129 particpants who were admitted to hospital with acute MI, 1043 with cardiac arrest and 4395 with stroke to 1 820 644, 307 375 and 888 481 controls, respectively. RESULTS: Fewer of the patients who were admitted to hospital were working 3 years postevent than controls for acute MI (by 5.0 percentage points [pp], 95% confidence interval [CI] 4.5-5.5), cardiac arrest (by 12.9 pp, 95% CI 10.4-15.3) and stroke (by 19.8 pp, 95% CI 18.5-23.5). Mean (95% CI) earnings declines attributable to the events were $3834 (95% CI 3346-4323) for acute MI, $11 143 (95% CI 8962-13 324) for cardiac arrest, and $13 278 (95% CI 12 301-14 255) for stroke. The effects on income were greater for patients who had lower baseline earnings, comorbid disease, longer hospital length of stay or needed mechanical ventilation. Sex, marital status or self-employment status did not affect income declines. INTERPRETATION: Acute MI, cardiac arrest and stroke all resulted in substantial loss in employment and earnings that persisted for at least 3 years after the events. These outcomes have consequences for patients, families, employers and governments. Identification of subgroups at high risk for these losses may assist in targeting interventions, policies and legislation to promote return to work.

Reassessing access to intensive care using an estimate of the population incidence of critical illness.

BACKGROUND: The consistently observed male predominance of patients in intensive care units (ICUs) has raised concerns about gender-based disparities in ICU access. Comparing rates of ICU admission requires choosing a normalizing factor (denominator), and the denominator usually used to compare such rates between subpopulations is the size of those subpopulations. However, the appropriate denominator is the number of people whose medical condition warranted ICU care. We devised an estimate of the number of critically ill people in the general population, and used it to compare rates of ICU admission by gender and income. METHODS: This population-based, retrospective analysis included all adults in the Canadian province of Manitoba, 2004-2015. We created an estimate for the number of critically ill people who warrant ICU care, and used it as the denominator to generate critical illness-normalized rates of ICU admission. These were compared to the usual population-normalized rates of ICU care. RESULTS: Men outnumbered women in ICUs for all age groups; population-normalized male:female rate ratios significantly exceed 0 for every age group, ranging from 1.15 to 2.10. Using critical-illness normalized rates, this male predominance largely disappeared; critically ill men and women aged 45-74 years were admitted in equivalent proportions (critical-illness normalized rate ratios 0.96-1.01). While population-normalized rates of ICU care were higher in lower income strata (p < 0.001), the gradient for critical illness-based rates was reversed (p < 0.001). CONCLUSIONS: Across a 30-year adult age span, the male predominance of ICU patients was accounted for by higher estimated rates of critical illness among men. People in lower income strata had lower critical-illness normalized rates of ICU admission. Our methods highlight that correct inferences about access to healthcare require calculating rates using denominators appropriate for this purpose.

Association between afterhours admission to the intensive care unit, strained capacity, and mortality: a retrospective cohort study.

BACKGROUND: Admission to the intensive care unit (ICU) outside daytime hours has been shown to be variably associated with increased morbidity and mortality. We aimed to describe the characteristics and outcomes of patients admitted to the ICU afterhours (22:00-06:59 h) in a large Canadian health region. We further hypothesized that the association between afterhours admission and mortality would be modified by indicators of strained ICU capacity. METHODS: This is a population-based cohort study of 12,265 adults admitted to nine ICUs in Alberta from June 2012 to December 2014. We used a path-analysis modeling strategy and mixed-effects multivariate regression analysis to evaluate direct and integrated associations (mediated through Acute Physiology and Chronic Health Evaluation (APACHE) II score) between afterhours admission (22:00-06:59 h) and ICU mortality. Further analysis examined the effects of strained ICU capacity and varied definitions of afterhours and weekend admissions. ICU occupancy ≥ 90% or clustering of admissions (≥ 0.15, defined as number of admissions 2 h before or after the index admission, divided by the number of ICU beds) were used as indicators of strained capacity. RESULTS: Of 12,265 admissions, 34.7% (n = 4251) occurred afterhours. The proportion of afterhours admissions varied amongst ICUs (range 26.7-37.8%). Patients admitted afterhours were younger (median (IQR) 58 (44-70) vs 60 (47-70) years, p < 0.0001), more likely to have a medical diagnosis (75.9% vs 72.1%, p < 0.0001), and had higher APACHE II scores (20.9 (8.6) vs 19.9 (8.3), p < 0.0001). Crude ICU mortality was greater for those admitted afterhours (15.9% vs 14.1%, p = 0.007), but following multivariate adjustment there was no direct or integrated effect on ICU mortality (odds ratio (OR) 1.024; 95% confidence interval (CI) 0.923-1.135, p = 0.658). Furthermore, direct and integrated analysis showed no association of afterhours admission and hospital mortality (p = 0.90) or hospital length of stay (LOS) (p = 0.27), although ICU LOS was shorter (p = 0.049). Early-morning admission (00:00-06:59 h) with ICU occupancy ≥ 90% was associated with short-term (≤ 7 days) and all-cause ICU mortality. CONCLUSIONS: One-third of critically ill patients are admitted to the ICU afterhours. Afterhours ICU admission was not associated with greater mortality risk in most circumstances but was sensitive to strained ICU capacity.