Burnout and fatigue amongst internal medicine residents: A cross-sectional study on the impact of alternative scheduling models on resident wellness.

BACKGROUND: Fatigue and burnout are prevalent among resident physicians across Canada. Shifts exceeding 24 hours are commonly purported as detrimental to resident health and performance. Residency training programs have employed strategies towards understanding and intervening upon the complex issue of resident fatigue, where alternative resident scheduling models have been an area of active investigation. This study sought to characterize drivers and outcomes of fatigue and burnout amongst internal medicine residents across different scheduling models. METHODS: We conducted cross-sectional surveys were among internal medicine resident physicians at the University of Alberta. We collected anonymized socioeconomic demographics and medical education background, and estimated associations between demographic or work characteristics and fatigue and burnout outcomes. RESULTS: Sixty-nine participants competed burnout questionnaires, and 165 fatigue questionnaires were completed (response rate of 48%). The overall prevalence of burnout was 58%. Lower burnout prevalence was noted among respondents with dependent(s) (p = 0.048), who identified as a racial minority (p = 0.018), or completed their medical degree internationally (p = 0.006). The 1-in-4 model was associated with the highest levels of fatigue, reported increased risk towards personal health (OR 4.98, 95%CI 1.77-13.99) and occupational or household harm (OR 5.69, 95%CI 1.87-17.3). Alternative scheduling models were not associated with these hazards. CONCLUSIONS: The 1-in-4 scheduling model was associated with high rates of resident physician fatigue, and alternative scheduling models were associated with less fatigue. Protective factors against fatigue are best characterized as strong social supports outside the workplace. Further studies are needed to characterize the impacts of alternative scheduling models on resident education and patient safety.

A scoping review of methods to measure and evaluate citizen engagement in health research.

BACKGROUND: Citizen engagement, or partnering with interested members of the public in health research, is becoming more common. While ongoing assessment of citizen engagement practices is considered important to its success, there is little clarity around aspects of citizen engagement that are important to assess (i.e., what to look for) and methods to assess (i.e., how to measure and/ or evaluate) citizen engagement in health research. METHODS: In this scoping review, we included peer-reviewed literature that focused primarily on method(s) to measure and/or evaluate citizen engagement in health research. Independently and in duplicate, we completed title and abstract screening and full-text screening and extracted data including document characteristics, citizen engagement definitions and goals, and methods to measure or evaluate citizen engagement (including characteristics of these methods). RESULTS: Our search yielded 16,762 records of which 33 records (31 peer-reviewed articles, one government report, one conference proceeding) met our inclusion criteria. Studies discussed engaging citizens (i.e., patients [n = 16], members of the public [n = 7], service users/consumers [n = 4], individuals from specific disease groups [n = 3]) in research processes. Reported methods of citizen engagement measurement and evaluation included frameworks, discussion-based methods (i.e., focus groups, interviews), survey-based methods (e.g., audits, questionnaires), and other methods (e.g., observation, prioritization tasks). Methods to measure and evaluate citizen engagement commonly focused on collecting perceptions of citizens and researchers on aspects of citizen engagement including empowerment, impact, respect, support, and value. DISCUSSION AND CONCLUSION: We found that methods to measure and/or evaluate citizen engagement in health research vary widely but share some similarities in aspect of citizen engagement considered important to measure or evaluate. These aspects could be used to devise a more standardized, modifiable, and widely applicable framework for measuring and evaluating citizen engagement in research. PATIENT OR PUBLIC CONTRIBUTION: Two citizen team members were involved as equal partners in study design and interpretation of its findings. SYSTEMATIC REVIEW REGISTRATION: Open Science Framework (10.17605/OSF.IO/HZCBR).

Involving members of the public (citizens) in health research is important. It helps make sure that research focuses on issues that are most important to citizens. It also helps ensure that the research done is respectful of citizen participation and most likely to provide benefit. However, the best way to engage citizens in research is unclear. In this scoping review, we examined existing studies that assessed citizen engagement in health research. We found that citizen engagement was often assessed by asking for feedback from both citizens and researchers. Feedback was collected in person (one on one interviews or group discussions) or in writing (using surveys or audits). Frameworks (organized ways of thinking about an issue) were also sometimes used to measure empowerment, impact, respect, support, and value of engaging citizens. It was clear from the frameworks that there is a need to develop clearer roles for citizens in research. The two citizen members of our research team who helped interpret our study findings felt that a set of guidelines for citizens to help them best participate in health research needs to be developed. We believe these observations could be used to create a more standard method for assessing citizen engagement in research.

Psychiatric Disorder Incidence Among Adolescents and Young Adults Aged 15-39 With Cancer: Population-Based Cohort.

BACKGROUND: Adolescent and young adult (AYA) cancer survivors face physical and psychological sequelae related to having cancer decades after treatment completion. It is unclear if AYA cancer survivors are at increased risk for late psychiatric disorders. METHODS: We used the Alberta AYA Cancer Survivor Study that includes 5-year survivors of cancer diagnosed at age 15-39 years during 1991 to 2013. The primary outcome was incidence of psychiatric disorder (composite outcome) including anxiety, depressive, trauma- and stressor-related, psychotic, and substance use disorders that were identified using coding algorithms for administrative health databases. A validated coding algorithm identified people who experienced a suicide attempt or event of self-harm. Secondary outcomes were incidences of diagnoses by type of psychiatric disorder. RESULTS: Among 12 116 AYA 5-year cancer survivors (n = 4634 [38%] males; n = 7482 [62%] females), 7426 (61%; n = 2406 [32%] males; n = 5020 [68%] females) were diagnosed with at least 1 of 5 psychiatric disorders occurring at least 3 years after cancer diagnosis. Survivors of all cancer types were most often diagnosed with anxiety (males: 39.0%, 95% confidence interval [CI] = 37.6% to 40.4%; females: 54.5%, 95% CI = 53.3% to 55.6%), depressive (males: 32.7%, 95% CI = 31.3% to 34.0%; females: 47.0%, 95% CI = 45.8% to 48.1%), and trauma- and stressor-related disorders (males: 13.5%, 95% CI =12.5% to 14.5%; females: 22.5%, 95% CI = 21.6% to 23.5%). CONCLUSIONS: Anxiety, depressive, and trauma- and stressor-related disorders are common among 5-year survivors of AYA cancer. Primary, secondary, or tertiary preventive strategies for AYAs diagnosed with cancer, particularly at an early age, are needed to mitigate risk of potentially severe outcomes because of psychiatric disorders.

Psychiatric Outcomes in ICU Patients With Family Visitation: A Population-Based Retrospective Cohort Study.

BACKGROUND: Lack of family visitation in the ICU can have long-term consequences on patients in the ICU after discharge. The effect of family visitation on the incidence of patient psychiatric disorders is unknown. RESEARCH QUESTION: What is the association between family visitation in the ICU and incidence of psychiatric outcomes in patients in the ICU 1 year after hospital discharge? STUDY DESIGN AND METHODS: This study assessed a population-based retrospective cohort of adult patients admitted to the ICU from January 1, 2014, through May 30, 2017, surviving to hospital discharge with ICU length of stay of ≥ 3 days. To be eligible, patients needed to have minimum of 5 years of administrative data before ICU admission and a minimum of 1 year of follow-up data after hospital discharge. An internally validated algorithm that interpreted natural language in health records determined patients with or without in-person family (ie, relatives, friends) visitation during ICU stay. The primary outcome was risk of an incidence of psychiatric disorder (composite outcome), including anxiety, depressive, trauma- and stressor-related, psychotic, and substance use disorders, identified using coding algorithms for administrative databases. Propensity scores were used in inverse probability weighted logistic regression models, and average treatment effects were converted to risk ratios (RRs) with 95% CIs. Secondary outcomes were incidences of diagnoses by type of psychiatric disorder. RESULTS: We included 14,344 patients with (96% [n = 13,771]) and without (4.0% [n = 573]) in-person family visitation who survived hospital discharge. More than one-third of patients received a diagnosis of any psychiatric disorder within 1 year after discharge (34.9%; 95% CI, 34.1%-35.6%). Patients most often received diagnoses of anxiety disorders (17.5%; 95% CI, 16.9%-18.1%) and depressive disorders (17.2%; 95% CI, 16.6%-17.9%). After inverse probability weighting of 13,731 patients, in-person family visitation was associated with a lower risk of received a diagnosis of any incident psychiatric disorder within 1 year after discharge (RR, 0.79; 95% CI, 0.68-0.92). INTERPRETATION: ICU family visitation is associated with a decreased risk of psychiatric disorders in critically ill patients up to 1 year after hospital discharge.

Optimal Glucose Target After Aneurysmal Subarachnoid Hemorrhage: A Matched Cohort Study.

BACKGROUND: Hyperglycemia has been associated with poor outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, there remains debate as to what optimal glucose targets should be in this patient population. OBJECTIVE: To assess whether we could identify an optimal glucose target for patients with aSAH. METHODS: We performed a post hoc analysis of the "clazosentan to overcome neurological ischemia and infarction occurring after subarachnoid hemorrhage" trial data set. Patients had laboratory results drawn daily for the entirety of their intensive care unit stay. Maximum blood glucose levels were assessed for a relationship with unfavorable outcomes using multiple logistic regression analysis. Maximum blood glucose levels were dichotomized based on the Youden index, which identified a maximum level of <9.2 mmol/L as the optimal cut point for prediction of unfavorable outcomes. Nearest neighbor matching was used to assess the relationship between maintaining glucose levels below the cut point and unfavorable functional outcomes (defined as a modified Rankin score of >2 at 3 mo post-aSAH). The matching was performed after calculation of a propensity score based on identified predictors of outcome and glucose levels. RESULTS: Three hundred eighty-nine patients were included in the matched analysis. Propensity scores were balanced on both the covariates and outcomes of interest. There was a significant average treatment effect (-0.143: 95% confidence interval -0.267 to -0.019) for patients who maintained glucose levels <9.2 mmol/L. CONCLUSION: Maintaining glucose levels below the identified cut point was associated with a decreased risk for unfavorable outcomes in this retrospective matched study.

Co-development of a transitions in care bundle for patient transitions from the intensive care unit: a mixed-methods analysis of a stakeholder consensus meeting.

BACKGROUND: Intensive care unit (ICU) patients undergoing transitions in care are at increased risk of adverse events and gaps in medical care. We evaluated existing patient- and family-centered transitions in care tools and identified facilitators, barriers, and implementation considerations for the application of a transitions in care bundle in critically ill adults (i.e., a collection of evidence-based patient- and family-centred tools to improve outcomes during and after transitions from the intensive care unit [ICU] to hospital ward or community). METHODS: We conducted a concurrent mixed methods (quan + QUAL) study, including stakeholders with experience in ICU transitions in care (i.e., patient/family partners, researchers, decision-makers, providers, and other knowledge-users). First, participants scored existing transitions in care tools using the modified Appraisal of Guidelines, Research and Evaluation (AGREE-II) framework. Transitions in care tools were discussed by stakeholders and either accepted, accepted with modifications, or rejected if consensus was achieved (≥70% agreement). We summarized quantitative results using frequencies and medians. Second, we conducted a qualitative analysis of participant discussions using grounded theory principles to elicit factors influencing AGREE-II scores, and to identify barriers, facilitators, and implementation considerations for the application of a transitions in care bundle. RESULTS: Twenty-nine stakeholders attended. Of 18 transitions in care tools evaluated, seven (39%) tools were accepted with modifications, one (6%) tool was rejected, and consensus was not reached for ten (55%) tools. Qualitative analysis found that participants' AGREE-II rankings were influenced by: 1) language (e.g., inclusive, balance of jargon and lay language); 2) if the tool was comprehensive (i.e., could stand alone); 3) if the tool could be individualized for each patient; 4) impact to clinical workflow; and 5) how the tool was presented (e.g., brochure, video). Participants discussed implementation considerations for a patient- and family-centered transitions in care bundle: 1) delivery (e.g., tool format and timing); 2) continuity (e.g., follow-up after ICU discharge); and 3) continuous evaluation and improvement (e.g., frequency of tool use). Participants discussed existing facilitators (e.g., collaboration and co-design) and barriers (e.g., health system capacity) that would impact application of a transitions in care bundle. CONCLUSIONS: Findings will inform future research to develop a transitions in care bundle for transitions from the ICU, co-designed with patients, families, providers, researchers, decision-makers, and knowledge-users.

The impact of patient delirium in the intensive care unit: patterns of anxiety symptoms in family caregivers.

BACKGROUND: The purpose of this study was to examine the association of patient delirium in the intensive care unit (ICU) with patterns of anxiety symptoms in family caregivers when delirium was determined by clinical assessment and family-administered delirium detection. METHODS: In this cross-sectional study, consecutive adult patients anticipated to remain in the ICU for longer than 24 h were eligible for participation given at least one present family caregiver (e.g., spouse, friend) provided informed consent (to be enrolled as a dyad) and were eligible for delirium detection (i.e., Richmond Agitation-Sedation Scale score ≥ - 3). Generalized Anxiety Disorder-7 (GAD-7) was used to assess self-reported symptoms of anxiety. Clinical assessment (Confusion Assessment Method for ICU, CAM-ICU) and family-administered delirium detection (Sour Seven) were completed once daily for up to five days. RESULTS: We included 147 family caregivers; the mean age was 54.3 years (standard deviation [SD] 14.3 years) and 74% (n = 129) were female. Fifty (34% [95% confidence interval [CI] 26.4-42.2]) caregivers experienced clinically significant symptoms of anxiety (median GAD-7 score 16.0 [interquartile range 6]). The most prevalent symptoms of anxiety were "Feeling nervous, anxious or on edge" (96.0% [95%CI 85.2-99.0]); "Not being able to stop or control worrying" (88.0% [95%CI 75.6-94.5]; "Worrying too much about different things" and "Feeling afraid as if something awful might happen" (84.0% [95%CI 71.0-91.8], for both). Family caregivers of critically ill adults with delirium were significantly more likely to report "Worrying too much about different things" more than half of the time (CAM-ICU, Odds Ratio [OR] 2.27 [95%CI 1.04-4.91]; Sour Seven, OR 2.28 [95%CI 1.00-5.23]). CONCLUSIONS: Family caregivers of critically ill adults with delirium frequently experience clinically significant anxiety and are significantly more likely to report frequently worrying too much about different things. Future work is needed to develop mental health interventions for the diversity of anxiety symptoms experienced by family members of critically ill patients. TRIAL REGISTRATION: This study is registered on ClinicalTrials.gov ( https://clinicaltrials.gov/ct2/show/NCT03379129 ).

Incorporating and evaluating citizen engagement in health research: a scoping review protocol.

BACKGROUND: Citizen engagement in research is an emerging practice that involves members of the general public in research processes such as priority setting, planning, decision-making, research conduct, implementation, evaluation, and dissemination. Engaging citizens in research, particularly health research, increases the relevance of study findings, minimizes waste by facilitating stewardship over resources, and builds public trust in the research. While several existing frameworks guide the application of citizen engagement principles to health research, it is unclear how citizen engagement can be utilized to maximize benefits and minimize risks and challenges in health research. To address the gaps in knowledge around citizen engagement in health research, we propose a scoping review to synthesize the state of knowledge on methods to incorporate and evaluate citizen engagement in research. A protocol is presented in this manuscript. METHODS: The methodology for our scoping review is guided by Arksey and O' Malley's framework for scoping reviews, and additional recommendations by Levac and colleagues. We will include peer-reviewed and gray literature that report on citizen engagement in health research (including biomedical, clinical, health systems and services, and social, cultural, environmental and population health) and report method(s) to conduct, measure, or evaluate citizen engagement. We will systematically search electronic databases (MEDLINE, EMBASE, CINAHL, JSTOR, PsycINFO, Scopus, and Science Direct) from inception onwards and search relevant organizations' websites for additional studies, frameworks, and reports on citizen engagement. Title and abstract and full-text citations will be screened independently and in duplicate. Data will be extracted independently and in duplicate, including document characteristics, citizen engagement definitions and goals, and outcomes of citizen engagement (e.g., barriers, facilitators). DISCUSSION: This review will synthesize the definitions, goals, methods, outcomes, and significance of citizen engagement in health research, as well as any potential barriers, facilitators, and challenges outlined in existing literature. The findings will provide an evidence-based foundation for developing new or improved guidance for citizen engagement in health research. Overall, we anticipate that our scoping review will be a preliminary step to meaningful engagement of citizens in research and strengthen the relationship between the scientific community and the public through transparency and collaboration. SYSTEMATIC REVIEW REGISTRATION: Open Science Framework  https://osf.io/hzcbr .

Comfort-holding in critically ill children: a scoping review.

PURPOSE: To understand and summarize the breadth of knowledge on comfort-holding in pediatric intensive care units (PICUs). SOURCES: This scoping review was conducted using PRISMA methodology. A literature search was conducted in MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane CENTRAL Register of Controlled Trials. Search strategies were developed with a medical librarian and revised through a peer review of electronic search strategies. All databases were searched from inception to 14 April 2020. Only full-text articles available in English were included. All identified articles were reviewed independently and in duplicate using predetermined criteria. All study designs were eligible if they reported on comfort-holding in a PICU. Data were extracted independently and in duplicate. PRINCIPAL FINDINGS: Of 13,326 studies identified, 13 were included. Comfort-holding was studied in the context of end-of-life care, developmental care, mobilization, and as a unique intervention. Comfort-holding is common during end-of-life care with 77.8% of children held, but rare during acute management (51% of children < three years, < 5% of children ≥ three years). Commonly reported outcomes included child outcomes (e.g., physiologic measurements), safety outcomes (e.g., accidental line removal), parent outcomes (e.g., psychological symptoms), and frequency of holding. CONCLUSION: There is a paucity of literature on comfort-holding in PICUs. This scoping review identifies significant gaps in the literature, including assessment of child-based outcomes of comfort-holding or safety assessment of comfort-holding, and highlights core outcomes to consider in future evaluations of this intervention including child-based outcomes, parent-based outcomes, and safety of the intervention.

RéSUMé: OBJECTIF: Comprendre et résumer l'étendue des connaissances sur la pratique des étreintes de réconfort dans les unités de soins intensifs pédiatriques (USIP). SOURCES: Cette étude de portée a été réalisée en utilisant la méthodologie PRISMA. Une recherche de la littérature a été menée dans les bases de données MEDLINE, EMBASE, PsycINFO, CINAHL et dans le registre Cochrane CENTRAL d'études contrôlées. Les stratégies de recherche ont été élaborées avec un bibliothécaire médical et révisées au moyen d'un examen par les pairs des stratégies de recherche électronique. Toutes les bases de données ont été passées en revue de leur création au 14 avril 2020. Seuls les articles en texte intégral disponibles en anglais ont été inclus. Tous les articles identifiés ont été révisés indépendamment et en double à l'aide de critères prédéterminés. Tous les types de plans d'étude étaient admissibles s'ils abordaient le thème des étreintes de réconfort dans une USIP. Les données ont été extraites indépendamment et en double. CONSTATATIONS PRINCIPALES: Sur les 13 326 études identifiées, 13 ont été incluses. Les étreintes de réconfort ont été étudiées dans le contexte des soins de fin de vie, des soins développementaux, de la mobilisation et en tant qu'intervention unique. Les étreintes de réconfort sont une approche courante dans le cadre de soins de fin de vie, durant lesquels 77,8 % des enfants sont étreints, mais plus rares pendant la prise en charge aiguë (51 % des enfants < trois ans, < 5 % des enfants ≥ trois ans). Les résultats couramment rapportés comprenaient les issues pour les enfants (p. ex. mesures physiologiques), les issues en matière de sécurité (p. ex. retrait accidentel d'une ligne), les issues pour les parents (p. ex. symptômes psychologiques) et la fréquence des étreintes. CONCLUSION: Il n'existe que très peu de littérature s'intéressant aux étreintes de réconfort dans les USIP. Cette étude de portée identifie d'importantes lacunes dans la littérature, notamment l'évaluation des issues pour l'enfant suite à une étreinte de réconfort ou l'évaluation de la sécurité de telles étreintes, et met en évidence les issues principales dont il faudra tenir compte dans les évaluations futures de cette intervention, y compris les issues axées sur l'enfant, les issues basées sur les parents et la sécurité de l'intervention.

Healthcare utilization and mortality outcomes in patients with pre-existing psychiatric disorders after intensive care unit discharge: A population-based retrospective cohort study.

PURPOSE: Pre-existing psychiatric disorders may lead to negative outcomes following intensive care unit (ICU) discharge. We evaluated the association of pre-existing psychiatric disorders with subsequent healthcare utilization and mortality in patients discharged from ICU. MATERIALS AND METHODS: We retrospectively studied adult patients admitted to 14 medical-surgical ICUs (January 2014-June 2016) with ICU length stay ≥24 h who survived to hospital discharge. Pre-existing psychiatric disorders were identified using algorithms for diagnostic codes captured ≤5 years before ICU admission. Outcomes were healthcare utilization (emergency department visit, hospital or ICU readmission) and mortality. We used logistic regression models with propensity scores to estimate associations, converted to risk ratios (RR). RESULTS: We included 10,598 patients. 37.6% (n = 3982) had a psychiatric history. Patients with pre-existing psychiatric disorders were at higher risk of subsequent emergency department visits (RR 1.49, 95%CI 1.29-1.71), hospital readmission (RR 1.49, 95%CI 1.34-1.66), ICU readmission (RR 2.64, 95%CI 1.55-4.49) one-year post-ICU discharge, compared to patients without pre-existing psychiatric disorders. Patients with pre-existing psychiatric disorders had a higher risk of mortality (RR 1.31, 95%CI 1.00-1.71) six-months post-ICU discharge. CONCLUSION: Critically ill patients with pre-existing psychiatric disorders have an increased risk of healthcare utilization and mortality outcomes following an ICU stay.

Wellness in medical education: definition and five domains for wellness among medical learners during the COVID-19 pandemic and beyond.

Problem: The novel coronavirus SARS-CoV-2 disease (COVID-19) impacted medical learner well-being and serves as a unique opportunity to understand medical learner wellness. The authors designed a formal needs assessment to assess medical learners' perspectives regarding distress related to disrupted training environments. This Rapid Communication describes findings from a qualitative study which defined medical learner wellness and validated five wellness domains.Approach: We conducted follow-up telephone interviews to an online needs assessment survey to identify a learner definition for wellness and to validate five wellness domains, including social, mental, physical, intellectual, and occupational wellness. Using purposive and maximal variation sampling, 27 students were interviewed from July-August 2020. Thematic analysis was performed using a deductive thematic approach to qualitative analysis.Outcomes: Medical learners defined wellness as a general [holistic] sense of personal well-being - the opportunity to be and to do what they most need and value. Learners validated all five wellness domains for medical education. Learners acknowledged the need for an adoptable and adaptable holistic framework for wellness in medical education.Next steps: We recommend academic medical institutions consider learner wellness a key component of medical education to cultivate learners as a competent collective of self-reliant, scholarly experts. We encourage evaluation of wellness domains in diverse medical learner populations to identify feasible interventions potentially associated with improvements in medical learner wellness.

Adverse events associated with administration of vasopressor medications through a peripheral intravenous catheter: a systematic review and meta-analysis.

BACKGROUND: It is unclear whether vasopressors can be safely administered through a peripheral intravenous (PIV). Systematic review and meta-analysis methodology was used to examine the incidence of local anatomic adverse events associated with PIV vasopressor administration in patients of any age cared for in any acute care environment. METHODS: MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of controlled trials, and the Database of Abstracts of Reviews of Effects were searched without restriction from inception to October 2019. References of included studies and related reviews, as well as relevant conference proceedings were also searched. Studies were included if they were: (1) cohort, quasi-experimental, or randomized controlled trial study design; (2) conducted in humans of any age or clinical setting; and (3) reported on local anatomic adverse events associated with PIV vasopressor administration. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials or the Joanna Briggs Institute checklist for prevalence studies where appropriate. Incidence estimates were pooled using random effects meta-analysis. Subgroup analyses were used to explore sources of heterogeneity. RESULTS: Twenty-three studies were included in the systematic review, of which 16 and 7 described adults and children, respectively. Meta-analysis from 11 adult studies including 16,055 patients demonstrated a pooled incidence proportion of adverse events associated with PIV vasopressor administration as 1.8% (95% CI 0.1-4.8%, I2 = 93.7%). In children, meta-analysis from four studies and 388 patients demonstrated a pooled incidence proportion of adverse events as 3.3% (95% CI 0.0-10.1%, I2 = 82.4%). Subgroup analyses did not detect any statistically significant effects associated with stratification based on differences in clinical location, risk of bias or design between studies, PIV location and size, or vasopressor type or duration. Most studies had high or some concern for risk of bias. CONCLUSION: The incidence of adverse events associated with PIV vasopressor administration is low. Additional research is required to examine the effects of PIV location and size, vasopressor type and dose, and patient characteristics on the safety of PIV vasopressor administration.

Associations between caregiver-detected delirium and symptoms of depression and anxiety in family caregivers of critically ill patients: a cross-sectional study.

BACKGROUND: Witnessing delirium can be distressing for family caregivers (i.e., relatives or friends) of critically ill patients. This study aimed to evaluate associations between caregiver-detected delirium in critically ill patients and depression and anxiety symptoms in their family caregivers. METHODS: Consecutive adult patient-caregiver dyads were enrolled from a 28-bed medical-surgical intensive care unit. Patient delirium was screened for daily by family caregivers using the Sour Seven instrument. Family caregivers completed the Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) instruments daily to assess their own depression and anxiety symptoms. Response feature analysis was used to handle repeated measures. Descriptive statistics and regression analyses were completed. RESULTS: One hundred forty-seven patient-caregiver dyads were enrolled. Clinically significant symptoms of depression and anxiety occurred in 27% and 35% of family caregivers, respectively. Caregiver-detected delirium occurred in 65% of patients, and was not associated with clinically significant caregiver depression (Odds Ratio [OR] 1.4, 95% Confidence Interval [95%CI] 0.6-3.1) or anxiety (OR 1.2, 95%CI 0.6-2.6) symptoms. When stratified by Sour Seven scores, scores 1-3 and 4-9 were associated with increased symptoms of anxiety (OR 3.1, 95%CI 1.3-7.0) and depression (OR 2.6, 95%CI 1.1-6.1) in family caregivers. Caregiver-detected delirium score was associated with severity of family caregiver anxiety symptoms (coefficient 0.2, 95%CI 0.1-0.4), but not depression symptoms (coefficient 0.2, 95%CI -0.0-0.3). CONCLUSIONS: Caregiver-detected patient delirium was associated with increased depression and anxiety symptoms in family caregivers of critically ill patients. Further randomized research is required to confirm these associations.

Mental Health Interventions to Improve Psychological Outcomes in Informal Caregivers of Critically Ill Patients: A Systematic Review and Meta-Analysis.

OBJECTIVES: Determine effect of mental health interventions on psychologic outcomes in informal caregivers of critically ill patients. DATA SOURCES: Searches conducted in MEDLINE, Embase, and other databases from inception to October 31, 2019. STUDY SELECTION: Interventions for informal caregivers of critically ill patients in adult ICU, PICU, or neonatal ICU. DATA EXTRACTION: Two independent, blinded reviewers screened citations and extracted data. Random-effects models with inverse variance weighting pooled outcome data when suitable. Psychologic outcomes categorized: 1) negative (anxiety, depression, post-traumatic stress disorder, distress, and burden) or 2) positive (courage, humanity, justice, transcendence, temperance, and wisdom and knowledge). Stratification according to intervention type and patient population was performed. DATA SYNTHESIS: Of 11,201 studies, 102 interventional trials were included (n = 12,676 informal caregivers). Interventions targeted caregiver experience (n = 58), role (n = 6), or support (n = 38). Meta-analysis (56 randomized controlled trials; n = 22 [39%] in adult ICUs; n = 34 [61%] in neonatal ICU or PICU) demonstrated reduced anxiety (ratio of means = 0.92; 95% CI, 0.87-0.97) and depression (ratio of means = 0.83; 95% CI, 0.69-0.99), but not post-traumatic stress disorder (ratio of means = 0.91; 95% CI, 0.80-1.04) or distress (ratio of means = 1.01; 95% CI, 0.95-1.07) among informal caregivers randomized to mental health interventions compared with controls within 3 months post-ICU discharge. Increased humanity (ratio of means = 1.11; 95% CI, 1.07-1.15), transcendence (ratio of means = 1.11; 95% CI, 1.07-1.15), and caregiver burden (ratio of means = 1.08; 95% CI, 1.05-1.12) were observed. No significant effects of mental health interventions observed after 3 months postdischarge. CONCLUSIONS: Mental health interventions for caregivers of critically ill patients improved short-term anxiety, depression, humanity, and transcendence while increasing burden. Clinicians should consider short-term prescriptions of mental health interventions to informal caregivers of critically ill patients with capacity to manage interventions.

The CAM-ICU-7 and ICDSC as measures of delirium severity in critically ill adult patients.

BACKGROUND: In clinical practice, a dichotomous approach to delirium identification may no longer be relevant when existing delirium screening tools measure a range of scores. The objective of this study was to compare the Confusion Assessment Method for the Intensive Care Unit 7-item (CAM-ICU-7) and the Intensive Care Delirium Screening Checklist (ICDSC) as measures of the spectrum of delirium severity in critically ill adult patients. METHODS: In this cross-sectional study, 218 patients underwent 641 paired assessments by bedside nurses (ICDSC, as per usual care) and trained research assistants (CAM-ICU-7). Correlation between the CAM-ICU-7 and ICDSC scores was evaluated. Logistic regression was used to explore associations between CAM-ICU-7 or ICDSC score and length of ICU stay and mechanical ventilation (receipt, ≥96 hours). RESULTS: Delirium prevalence evaluated by the CAM-ICU-7 and ICDSC were 46.3% (95% CI:39.7-53.0) and 34.4% (95% CI:28.3-41.0). Prevalence of less than clinical threshold symptoms of delirium evaluated by the CAM-ICU-7 (score: 1-2) and ICDSC (score: 1-3) were 30.3% (95%CI:24.5-36.7) and 50.9% (95%CI:44.3-57.6). The CAM-ICU-7 and ICDSC had significant positive correlation (0.58, p<0.001). Agreement between the tools as measures of delirium was moderate (kappa = 0.51) and as measures of less than clinical threshold symptoms of delirium was fair (kappa = 0.21). Less than clinical threshold symptoms of delirium identified by the ICDSC, not CAM-ICU-7, were associated with prolonged length of ICU stay (≥7 days) in patients <65 years of age [Odds Ratio (OR) 9.2, 95% CI:2.5-34.0] and mechanical ventilation (receipt: OR 2.8, 95% CI:1.3-6.4; ≥96 hours: OR 6.6, 95% CI:1.9-22.9), when compared to patients with no delirium. CONCLUSIONS: The CAM-ICU-7 and ICDSC are measures of the spectrum of delirium severity that are closely correlated. Less than clinical threshold symptoms of delirium measure by the ICDSC is a better predictor of outcomes, when compared with the CAM-ICU-7.

Impact of social media interventions and tools among informal caregivers of critically ill patients after patient admission to the intensive care unit: A scoping review.

BACKGROUND: The use of social media in healthcare continues to evolve. The purpose of this scoping review was to summarize existing research on the impact of social media interventions and tools among informal caregivers of critically ill patients after patient admission to the intensive care unit (ICU). METHODS: This review followed established scoping review methods, including an extensive a priori-defined search strategy implemented in the MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane CENTRAL Register of Controlled Trials databases to July 10, 2020. Primary research studies reporting on the use of social media by informal caregivers for critically ill patients were included. RESULTS: We identified 400 unique citations and thirty-one studies met the inclusion criteria. Nine were interventional trials-four randomized controlled trials (RCTs)-and a majority (n = 14) were conducted (i.e., data collected) between 2013 to 2015. Communication platforms (e.g., Text Messaging, Web Camera) were the most commonly used social media tool (n = 17), followed by social networking sites (e.g., Facebook, Instagram) (n = 6), and content communities (e.g., YouTube, SlideShare) (n = 5). Nine studies' primary objective was caregiver satisfaction, followed by self-care (n = 6), and health literacy (n = 5). Nearly every study reported an outcome on usage feasibility (e.g., user attitudes, preferences, demographics) (n = 30), and twenty-three studies reported an outcome related to patient and caregiver satisfaction. Among the studies that assessed statistical significance (n = 18), 12 reported statistically significant positive effects of social media use. Overall, 16 of the 31 studies reported positive conclusions (e.g., increased knowledge, satisfaction, involvement) regarding the use of social media among informal caregivers for critically ill patients. CONCLUSIONS: Social media has potential benefits for caregivers of the critically ill. More robust and clinically relevant studies are required to identify effective social media strategies used among caregivers for the critically ill.

The association of delirium severity with patient and health system outcomes in hospitalised patients: a systematic review.

BACKGROUND: delirium is an acute state of confusion that affects >20% of hospitalised patients. Recent literature indicates that more severe delirium may lead to worse patient outcomes and health system outcomes, such as increased mortality, cognitive impairment and length of stay (LOS). METHODS: using systematic review methodology, we summarised associations between delirium severity and patient or health system outcomes in hospitalised adults. We searched MEDLINE, EMBASE, PsycINFO, CINAHL and Scopus databases with no restrictions, from inception to 25 October 2018. We included original observational research conducted in hospitalised adults that reported on associations between delirium severity and patient or health system outcomes. Quality of included articles was assessed using the Newcastle-Ottawa Scale. The level of evidence was quantified based on the consistency of findings and quality of studies reporting on each outcome. RESULTS: we included 20 articles evaluating associations that reported: mortality (n = 11), cognitive ability (n = 3), functional ability (n = 3), patient distress (n = 1), quality of life (n = 1), hospital LOS (n = 4), intensive care unit (ICU) LOS (n = 2) and discharge home (n = 2). There was strong-level evidence that delirium severity was associated with increased ICU LOS and a lower proportion of patients discharged home. There was inconclusive evidence for associations between delirium severity and mortality, hospital LOS, functional ability, cognitive ability, patient distress and quality of life. CONCLUSION: delirium severity is associated with increased ICU LOS and a lower proportion of patients discharged home. Delirium severity may be a useful adjunct to existing delirium screening to determine the burden to health care system resources.