Study of Rivaroxaban for Cerebral Venous Thrombosis: A Randomized Controlled Feasibility Trial Comparing Anticoagulation With Rivaroxaban to Standard-of-Care in Symptomatic Cerebral Venous Thrombosis.

BACKGROUND: Emerging data suggest that direct oral anticoagulants may be a suitable choice for anticoagulation for cerebral venous thrombosis (CVT). However, conducting high-quality trials in CVT is challenging as it is a rare disease with low rates of adverse outcomes such as major bleeding and functional dependence. To facilitate the design of future CVT trials, SECRET (Study of Rivaroxaban for Cerebral Venous Thrombosis) assessed (1) the feasibility of recruitment, (2) the safety of rivaroxaban compared with standard-of-care anticoagulation, and (3) patient-centered functional outcomes. METHODS: This was a phase II, prospective, open-label blinded-end point 1:1 randomized trial conducted at 12 Canadian centers. Participants were aged ≥18 years, within 14 days of a new diagnosis of symptomatic CVT, and suitable for oral anticoagulation; they were randomized to receive rivaroxaban 20 mg daily, or standard-of-care anticoagulation (warfarin, target international normalized ratio, 2.0-3.0, or low-molecular-weight heparin) for 180 days, with optional extension up to 365 days. Primary outcomes were annual rate of recruitment (feasibility); and a composite of symptomatic intracranial hemorrhage, major extracranial hemorrhage, or mortality at 180 days (safety). Secondary outcomes included recurrent venous thromboembolism, recanalization, clinically relevant nonmajor bleeding, and functional and patient-reported outcomes (modified Rankin Scale, quality of life, headache, mood, fatigue, and cognition) at days 180 and 365. RESULTS: Fifty-five participants were randomized. The rate of recruitment was 21.3 participants/year; 57% of eligible candidates consented. Median age was 48.0 years (interquartile range, 38.5-73.2); 66% were female. There was 1 primary event (symptomatic intracranial hemorrhage), 2 clinically relevant nonmajor bleeding events, and 1 recurrent CVT by day 180, all in the rivaroxaban group. All participants in both arms had at least partial recanalization by day 180. At enrollment, both groups on average reported reduced quality of life, low mood, fatigue, and headache with impaired cognitive performance. All metrics improved markedly by day 180. CONCLUSIONS: Recruitment targets were reached, but many eligible participants declined randomization. There were numerically more bleeding events in patients taking rivaroxaban compared with control, but rates of bleeding and recurrent venous thromboembolism were low overall and in keeping with previous studies. Participants had symptoms affecting their well-being at enrollment but improved over time. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03178864.

A queuing model for ventilator capacity management during the COVID-19 pandemic.

We applied a queuing model to inform ventilator capacity planning during the first wave of the COVID-19 epidemic in the province of British Columbia (BC), Canada. The core of our framework is a multi-class Erlang loss model that represents ventilator use by both COVID-19 and non-COVID-19 patients. Input for the model includes COVID-19 case projections, and our analysis incorporates projections with different levels of transmission due to public health measures and social distancing. We incorporated data from the BC Intensive Care Unit Database to calibrate and validate the model. Using discrete event simulation, we projected ventilator access, including when capacity would be reached and how many patients would be unable to access a ventilator. Simulation results were compared with three numerical approximation methods, namely pointwise stationary approximation, modified offered load, and fixed point approximation. Using this comparison, we developed a hybrid optimization approach to efficiently identify required ventilator capacity to meet access targets. Model projections demonstrate that public health measures and social distancing potentially averted up to 50 deaths per day in BC, by ensuring that ventilator capacity was not reached during the first wave of COVID-19. Without these measures, an additional 173 ventilators would have been required to ensure that at least 95% of patients can access a ventilator immediately. Our model enables policy makers to estimate critical care utilization based on epidemic projections with different transmission levels, thereby providing a tool to quantify the interplay between public health measures, necessary critical care resources, and patient access indicators.

A survey of health care practitioners' attitudes toward shared decision-making for choice of next birth after cesarean.

BACKGROUND: Patients with a history of cesarean may benefit from shared decision-making (SDM) interventions, such as patient decision aids, that provide individualized clinical information and help to clarify personal preferences. We sought to understand the factors that influence how care practitioners support choices for mode of birth and what individual and health system factors influence uptake of SDM in routine care. METHODS: We conducted a cross-sectional survey of health care practitioners in British Columbia, Canada (2016-2017). Participants included family physicians, midwives, obstetricians, and registered nurses. We conducted descriptive and inferential analyses of quantitative data and subjected the open-ended survey responses to thematic analysis. RESULTS: Analysis of survey responses (n = 307) suggested there was no significant association between the size of the participant hospital and their medico-legal concerns about mode of birth. Environmental factors that may influence the use of SDM included the length of time it takes to initiate an emergency cesarean and the timing of when the SDM intervention is introduced to the patient. No participants reported protocols prohibiting VBAC at their hospital. Participants preferred an SDM approach where the pregnant person is involved in making the final decision for mode of birth. CONCLUSIONS: Although maternity care practitioners express attitudes and behaviors that may support SDM for mode of birth after cesarean, implementing SDM using a patient decision aid alone may be challenging because of environmental factors. Our study demonstrates how survey data can aid in identifying how, when, where, for whom, and why an SDM intervention could be implemented.

Clinically significant substance use and residential stability among homeless or vulnerably housed persons in Canada: a longitudinal cohort study.

BACKGROUND: We examined clinically significant substance use among homeless or vulnerably housed persons in three Canadian cities and its association with residential stability over time using data from the Health and Housing in Transition study. METHODS: In 2009, 1190 homeless or vulnerably housed individuals were recruited in three Canadian cities and followed for 4 years. We collected information on housing and incarceration history, drug and alcohol use, having a primary care provider at baseline and annually for 4 years. Participants who screened positive for substance use at baseline were included in the analyses. We used a generalized logistic mixed effect regression model to examine the association between clinically significant substance use and residential stability, adjusting for confounders. RESULTS: Initially, 437 participants met the criteria for clinically significant substance use. The proportion of clinically significant substance use declined, while the proportion of participants who achieved residential stability increased over time. Clinically significant substance use was negatively associated with achieving residential stability over the 4-year period (AOR 0.7; 95% CI 0.57, 0.86). CONCLUSIONS: In this cohort of homeless or vulnerably housed individuals, clinically significant substance use was negatively associated with achieving residential stability over time, highlighting the need to better address substance use in this population.

The Association of Residential Instability and Hospitalizations among Homeless and Vulnerably Housed Individuals: Results from a Prospective Cohort Study.

The present study examined the association of residential instability with hospitalizations among homeless and vulnerably housed individuals over a 4-year time period. Survey data were linked to administrative records on hospitalizations. Specifically, we used data from the Health and Housing in Transition study, a prospective cohort study that tracked the health and housing status of homeless and vulnerably housed individuals in Canada. Responses from Vancouver-based participants (n = 378) from baseline and 3 follow-ups were linked to their administrative health records on hospitalizations (Discharge Abstract Database - Hospital Separation Files; 2008-2012). A generalized estimating equations model was used to examine associations between the number of residential moves and any hospitalizations during each year (none versus ≥ 1 hospitalizations). Analyses included demographic and health variables. Survey data were collected via structured interviews. Hospitalizations were derived from provincial administrative health records. A higher number of residential moves were associated with hospitalization over the study period (adjusted odds ratio: 1.14; 95% confidence interval: 1.01, 1.28). Transgender, female gender, perceived social support, better self-reported mental health, and having ≥ 3 chronic health conditions also predicted having been hospitalized over the study period, whereas high school/higher education was negatively associated with hospitalizations. Our results indicate that residential instability is associated with increased risk of hospitalization, illustrating the importance of addressing housing as a social determinant of health.

Concurrent Disorders and Health Care Utilization Among Homeless and Vulnerably Housed Persons in Canada.

OBJECTIVE: Individuals who are homeless or vulnerably housed have a higher prevalence of concurrent disorders, defined as having a mental health diagnosis and problematic substance use, compared to the general housed population. The study objective was to investigate the effect of having concurrent disorders on health care utilization among homeless or vulnerably housed individuals, using longitudinal data from the Health and Housing in Transition Study. METHODS: In 2009, 1190 homeless or vulnerably housed adults were recruited in Ottawa, Toronto, and Vancouver, Canada. Participants completed baseline interviews and four annual follow-up interviews, providing data on sociodemographics, housing history, mental health diagnoses, problematic drug use with the Drug Abuse Screening Test (DAST-10), problematic alcohol use with the Alcohol Use Disorders Identification Test (AUDIT), chronic health conditions, and utilization of the following health care services: emergency department (ED), hospitalization, and primary care. Concurrent disorders were defined as the participant having ever received a mental health diagnosis at baseline and having problematic substance use (i.e., DAST-10 ≥ 6 and/or AUDIT ≥ 20) at any time during the study period. Three generalized mixed effects logistic regression models were used to examine the independent association of having concurrent disorders and reporting ED use, hospitalization, or primary care visits in the past 12 months. RESULTS: Among our sample of adults who were homeless or vulnerably housed, 22.6% (n = 261) reported having concurrent disorders at baseline. Individuals with concurrent disorders had significantly higher odds of ED use (adjusted odds ratio [AOR] = 1.71; 95% confidence interval [CI], 1.4-2.11), hospitalization (AOR = 1.45; 95% CI, 1.16-1.81), and primary care visits (AOR = 1.34; 95% CI, 1.05-1.71) in the past 12 months over the four-year follow-up period, after adjusting for potential confounders. CONCLUSIONS: Concurrent disorders were associated with higher rates of health care utilization when compared to those without concurrent disorders among homeless and vulnerably housed individuals. Comprehensive programs that integrate mental health and addiction services with primary care as well as community-based outreach may better address the unmet health care needs of individuals living with concurrent disorders who are vulnerable to poor health outcomes.

Residential Stability Reduces Unmet Health Care Needs and Emergency Department Utilization among a Cohort of Homeless and Vulnerably Housed Persons in Canada.

This study examined the association of housing status over time with unmet physical health care needs and emergency department utilization among homeless and vulnerably housed persons in Canada. Homeless and vulnerably housed individuals completed interviewer-administered surveys on housing, unmet physical health care needs, health care utilization, sociodemographic characteristics, substance use, and health conditions at baseline and annually for 4 years. Generalized logistic mixed effects regression models examined the association of residential stability with unmet physical health care needs and emergency department utilization, adjusting for potential confounders. Participants were from Vancouver (n = 387), Toronto (n = 390), and Ottawa (n = 396). Residential stability was associated with lower odds of having unmet physical health needs (adjusted odds ratio (AOR), 0.82; 95 % confidence interval (CI), 0.67, 0.98) and emergency department utilization (AOR, 0.74; 95 % CI, 0.62, 0.88) over the 4-year follow-up period, after adjusting for potential confounders. Residential stability is associated with fewer unmet physical health care needs and lower emergency department utilization among homeless and vulnerably housed individuals. These findings highlight the need to address access to stable housing as a significant determinant of health disparities.

Assessing the Influence of Intensive Care Unit Organizational Factors on Outcomes in Canada: Is There Residual Confounding?

OBJECTIVE: To illustrate the complexities of assessing the influence of individual organizational factors on outcomes for intensive care unit (ICU) patients in Canada. METHODS: In this cross-sectional study, we used retrospectively collected data from all patients admitted to all ICUs in British Columbia between April 01, 1994, and March 31, 1999, or to 20 ICUs in Ontario during 2002. We used responses to a survey about organizational factors for all ICUs in British Columbia and Ontario that was done in 2001. Clustered data regression models were used to assess the influence of organizational factors on outcomes after adjustment for patient-level confounders. RESULTS: Despite adjustment for age, sex, comorbidity score of patients, and limitation of the data sets to minimize confounding, we found variable relationships between ICU outcomes (hospital mortality, ICU length of stay, and hospital length of stay) and any of "closed" administrative model, daily rounds, presence of an ICU medical director, medical director trained in critical care medicine, presence of a nurse leader in the ICU, nurse-patient ratio, and presence of an ICU pharmacist. Closed administrative model was associated with lower hospital mortality (odds ratio [95% confidence interval]: 0.75 [0.66-0.85]), shorter length of ICU stay (rate ratio [95% confidence interval]: 0.76 [0.62-0.92]), and shorter length of hospital stay (rate ratio [5% confidence interval]: 0.78 [0.72-0.84]) in nontertiary ICUs but many other "advantageous" factors were associated with higher mortality. CONCLUSIONS: The lack of a consistent relationship between organizational factors and ICU outcomes, and relationships that show increased mortality associated with some advantageous factors, suggests that there is residual confounding in these relationships. Models that adjust for only conventional patient-level confounders are unlikely to provide valid estimates of the influence of organizational factors.

Association between source of infection and hospital mortality in patients who have septic shock.

RATIONALE: Mortality caused by septic shock may be determined by a systemic inflammatory response, independent of the inciting infection, but it may also be influenced by the anatomic source of infection. OBJECTIVES: To determine the association between the anatomic source of infection and hospital mortality in critically ill patients who have septic shock. METHODS: This was a retrospective, multicenter cohort study of 7,974 patients who had septic shock in 29 academic and community intensive care units in Canada, the United States, and Saudi Arabia from January 1989 to May 2008. MEASUREMENTS AND MAIN RESULTS: Subjects were assigned 1 of 20 anatomic sources of infection based on clinical diagnosis and/or isolation of pathogens. The primary outcome was hospital mortality. Overall crude hospital mortality was 52% (21-85% across sources of infection). Variation in mortality remained after adjusting for year of admission, geographic source of admission, age, sex, comorbidities, community- versus hospital-acquired infection, and organism type. The source of infection with the highest standardized hospital mortality was ischemic bowel (75%); the lowest was obstructive uropathy-associated urinary tract infection (26%). Residual variation in adjusted hospital mortality was not explained by Acute Physiology and Chronic Health Evaluation II score, number of Day 1 organ failures, bacteremia, appropriateness of empiric antimicrobials, or adjunct therapies. In patients who received appropriate antimicrobials after onset of hypotension, source of infection was associated with death after adjustment for both predisposing and downstream factors. CONCLUSIONS: Anatomic source of infection should be considered in future trial designs and analyses, and in development of prognostic scoring systems.

A randomized, clinical trial investigating the use of a digital intervention to reduce delirium-associated agitation.

We aimed to determine if a novel digital therapeutic intervention could reduce agitation and unscheduled medication use in an adult delirious acute care population. Delirious participants were randomly allocated (1:1) to receive standard of care plus a single 4-hour exposure to the digital intervention "MindfulGarden", which uses a screen-based delivery to display a nature landscape with dynamic adjustment of screen content in response to movement and sound or standard of care only. Between March 2021 and January 2022, 73 participants were enrolled with 70 completing the trial protocol and included in the final analysis with a mean age of 61 years and 68% being male (35 intervention, 35 control). Mean RASS was significantly lower across the 4-hour study period in the intervention arm 0.3 (0.85) vs 0.9 (0.93), p = 0.01. Exposure to a nature-based dynamic digital intervention showed benefits in agitation reduction.

Association Between the Pulmonary Artery Pulsatility Index and Prognosis in Pulmonary Arterial Hypertension: A Multicentre Study.

Background: Risk stratification is fundamental in the management of pulmonary arterial hypertension (PAH). Pulmonary artery pulsatility index (PAPi), defined as pulmonary arterial pulse pressure divided by right atrial pressure (RAP), is a hemodynamic index shown to predict acute right ventricular (RV) dysfunction in several settings. Our objective was to test the prognostic utility of PAPi in a diverse multicentre cohort of patients with PAH. Methods: A multicentre retrospective cohort study of consecutive adult patients with a new diagnosis of PAH on right heart catheterization between January 2016 and December 2020 was undertaken across 4 major centres in Canada. Hemodynamic data, clinical data, and outcomes were collected. The association of PAPi and other hemodynamic variables with mortality was assessed by receiver-operating characteristic curves and Cox proportional hazards modeling. Results: We identified 590 patients with a mean age of 61.4 ± 15.5 years, with 66.3% being female. A low PAPi (defined as < 5.3) was associated with higher mortality at 1 year: 10.2% vs 5.2% (P = 0.02). In a multivariable model including age, sex, body mass index, and functional class, a low PAPi was associated with mortality at 1 year (area under the curveof 0.64 (95% confidence interval 0.55-0.74). However, high RAP (> 8 mm Hg) was similarly predictive of mortality, with an area under the curve of 0.65. Conclusion: PAPi was associated with mortality in a large incident PAH cohort. However, the discriminative value of PAPi was not higher than that of RAP alone.

Contexte: La stratification des risques est fondamentale dans la prise en charge de l'hypertension artérielle pulmonaire (HTAP). L'indice de pulsatilité des artères pulmonaires (iPAP), défini comme la pression différentielle dans les artères pulmonaires divisée par la pression auriculaire droite (PAD), est un indice hémodynamique qui s'est révélé prédictif d'une dysfonction ventriculaire droite (VD) aiguë dans plusieurs situations. Notre objectif était d'évaluer l'utilité pronostique de l'iPAP dans une cohorte multicentrique diversifiée de patients atteints d'HTAP. Méthodologie: Une étude de cohorte multicentrique rétrospective de patients adultes consécutifs atteints d'une HTAP nouvellement diagnostiquée par cathétérisme cardiaque droit entre janvier 2016 et décembre 2020 a été effectuée dans quatre grands centres au Canada. Les données hémodynamiques, les données cliniques et les résultats ont été recueillis. La corrélation de l'iPAP et d'autres va-riables hémodynamiques avec la mortalité a été évaluée par les courbes caractéristiques opérationnelles du receveur et des modèles à risques proportionnels de Cox. Résultats: Nous avons recensé 590 patients dont l'âge moyen était de 61,4 ± 15,5 ans; la proportion de femmes était de 66,3 %. Un faible iPAP (défini comme une valeur < 5,3) a été associé à une hausse de la mortalité à 1 an : 10,2 % contre 5,2 % (p= 0,02). Dans un modèle multivarié comprenant l'âge, le sexe, l'indice de masse corporelle et la classe fonctionnelle, un faible iPAP a été associé à la mortalité à 1 an (aire sous la courbe de 0,64 [intervalle de confiance à 95 %; de 0,55 à 0,74]). Cependant, une PAD élevée (> 8 mmHg) a aussi été un facteur prédictif de mortalité, l'aire sous la courbe étant de 0,65. Conclusions: L'iPAP a été associé à la mortalité dans une vaste cohorte de patients atteints d'une HTAP. Toutefois, la valeur discriminante de l'iPAP n'a pas été supérieure à celle de la PAD seule.

Does community size or commute time affect severity of illness at diagnosis or quality of care in a centralized care model of pulmonary hypertension?

BACKGROUND: Centralized care models are often used for rare diseases like pulmonary hypertension (PH). It is unknown how living in a rural or remote area influences outcomes. METHODS: We identified all patients from our PH database who carried a diagnosis of WHO Group 1 or WHO Group 4 PH. Using Canadian postal code data, patients were classified as living in a rural area; or a small, medium or large community size. The commute time from patient residence to our clinic was determined using mapping software. We compared baseline catheterization data according to community size and commute time. At follow up, we evaluated the association between community size and commute time with prognostic parameters of functional class, walk distance and echocardiography. RESULTS: Of the 342 patients identified, 72(21%) patients lived in rural areas, while 26(8%), 49(14%) and 195(57%) resided in small, medium and large population centres, respectively. The commute time was <1 h for 160(47%), 1-3 h for 62(18%), and >3 h for 120(35%). There was no association seen for any catheterization parameter by either community size or commute time. At last follow up, there was no association between any prognostic parameter and community size or commute time. CONCLUSIONS: We found no association between community size or commute time with severity of illness at diagnosis, or markers of prognosis at follow up. This suggests that patients who reside in rural or remote environments are not experiencing deficiencies in care compared to urban patients.

Assessment of an Interactive Digital Health-Based Self-management Program to Reduce Hospitalizations Among Patients With Multiple Chronic Diseases: A Randomized Clinical Trial.

Importance: Digital health programs may have the potential to prevent hospitalizations among patients with chronic diseases by supporting patient self-management, symptom monitoring, and coordinated care. Objective: To compare the effect of an internet-based self-management and symptom monitoring program targeted to patients with 2 or more chronic diseases (internet chronic disease management [CDM]) with usual care on hospitalizations over a 2-year period. Design, Setting, and Participants: This single-blinded randomized clinical trial included patients with multiple chronic diseases from 71 primary care clinics in small urban and rural areas throughout British Columbia, Canada. Recruitment occurred between October 1, 2011, and March 23, 2015. A volunteer sample of 456 patients was screened for eligibility. Inclusion criteria included daily internet access, age older than 19 years, fluency in English, and the presence of 2 or more of the following 5 conditions: diabetes, heart failure, ischemic heart disease, chronic kidney disease, or chronic obstructive pulmonary disease. A total of 230 patients consented to participate and were randomized to receive either the internet CDM intervention (n = 117) or usual care (n = 113). One participant in the internet CDM group withdrew from the study after randomization, resulting in 229 participants for whom data on the primary outcome were available. Interventions: Internet-based self-management program using telephone nursing supports and integration within primary care compared with usual care over a 2-year period. Main Outcomes and Measures: The primary outcome was all-cause hospitalizations at 2 years. Secondary outcomes included hospital length of stay, quality of life, self-management, and social support. Additional outcomes included the number of participants with at least 1 hospitalization, the number of participants who experienced a composite outcome of all-cause hospitalization or death, the time to first hospitalization, and the number of in-hospital days. Results: Among 229 participants included in the analysis, the mean (SD) age was 70.5 (9.1) years, and 141 participants (61.6%) were male; data on race and ethnicity were not collected because there was no planned analysis of these variables. The internet CDM group had 25 fewer hospitalizations compared with the usual care group (56 hospitalizations vs 81 hospitalizations, respectively [30.9% reduction]; relative risk [RR], 0.68; 95% CI, 0.43-1.10; P = .12). The intervention group also had 229 fewer in-hospital days compared with the usual care group (282 days vs 511 days, respectively; RR, 0.52; 95% CI, 0.24-1.10; P = .09). Components of self-management and social support improved in the intervention group. Fewer participants in the internet CDM vs usual care group had at least 1 hospitalization (32 of 116 individuals [27.6%] vs 46 of 113 individuals [40.7%]; odds ratio [OR], 0.55; 95% CI, 0.31-0.96; P = .03) or experienced the composite outcome of all-cause hospitalization or death (37 of 116 individuals [31.9%] vs 51 of 113 individuals [45.1%]; OR, 0.57; 95% CI, 0.33-0.98; P = .04). Participants in the internet CDM group had a lower risk of time to first hospitalization (hazard ratio, 0.62; 95% CI, 0.39-0.97; P = .04) than those in the usual care group. Conclusions and Relevance: In this study, an internet-based self-management program did not result in a significant reduction in hospitalization. However, fewer participants in the intervention group were admitted to the hospital or experienced the composite outcome of all-cause hospitalization or death. These findings suggest the internet CDM program has the potential to augment primary care among patients with multiple chronic diseases. Trial Registration: ClinicalTrials.gov Identifier: NCT01342263.

Structure, process, and outcome of all intensive care units within the province of British Columbia, Canada.

PURPOSE: To describe the total and regional capacity for critical care in British Columbia (BC), Canada, and to describe regional variation in number of intensive care units (ICUs), size of ICUs, length of ICU stay, ICU occupancy, key processes of critical care, and hospital mortality for ICU patients in B.C. METHODS: In this cross-sectional study, we used retrospectively collected data from all patients admitted to an ICU in BC between April 1, 1998, and March 31, 1999, and responses to a survey about organizational factors for all ICUs in BC that was done in 2001 and updated in 2008. RESULTS: The number of ICU beds in each geographic region in BC is inversely related to the population density and population growth within those regions. In addition, the distribution of ICU beds does not match the distribution of specialized and high-risk clinical services. There is wide variation by geographic region and by size of ICU in physician and nurse staffing, physician model of care, availability and participation of respiratory therapists, and other support services in clinical care and in reported use of clinical practice guidelines. CONCLUSION: Variation and lack of availability of key processes for care of critically ill patients in this population identifies opportunities for knowledge translation and systematic improvement including regionalization of care.

Decision aid for early identification of acute underlying illness in emergency department patients with atrial fibrillation or flutter.

BACKGROUND: Emergency department (ED) patients with atrial fibrillation or flutter (AFF) with underlying occult condition such as sepsis or heart failure, and who are managed with rate or rhythm control, have poor prognoses. Such conditions may not be easy to identify early in the ED evaluation when critical treatment decisions are made. We sought to develop a simple decision aid to quickly identify undifferentiated ED AFF patients who are at high risk of acute underlying illness. METHODS: We collected consecutive ED patients with electrocardiogram-proven AFF over a 1-year period and performed a chart review to ascertain demographics, comorbidities, and investigations. The primary outcome was having an acute underlying illness according to prespecified criteria. We used logistic regression to identify factors associated with the primary outcome, and developed criteria to identify those with an underlying illness at presentation. RESULTS: Of 1,083 consecutive undifferentiated ED AFF patients, 400 (36.9%) had an acute underlying illness; they were older with more comorbidities. Modeling demonstrated that three predictors (ambulance arrival; chief complaint of chest pain, dyspnea, or weakness; CHA2DS2-VASc score greater than 2) identified 93% of patients with acute underlying illness (95% confidence interval [CI], 91-96%) with 54% (95% CI, 50-58%) specificity. The decision aid missed 28 patients; (7.0%) simple blood tests and chest radiography identified all within an hour of presentation. CONCLUSIONS: In ED patients with undifferentiated AFF, this simple predictive model rapidly differentiates patients at risk of acute underlying illness, who will likely merit investigations before AFF-specific therapy.

Consecutive nursing shifts and the risk of hypoglycemia in critically ill patients who are receiving intravenous insulin: a multicenter study.

STUDY OBJECTIVES: Intensive care unit nurses commonly work multiple consecutive 12-hour shifts that leave little time for sleep between work shifts. Working multiple consecutive shifts could compromise vigilance and patient care, especially with respect to managing high-risk medications such as insulin infusions. We hypothesized that as the number of consecutive shifts worked by nurses increases, the rate of hypoglycemia in patients who are receiving an insulin infusion would also increase. METHODS: We identified patients who had hypoglycemia (glucose ≤ 3.5 mmol/L, 63 mg/dL) between December 2008 and December 2009 in 3 intensive care units in Vancouver, British Columbia, Canada. For each hypoglycemic event, we counted the number of shifts worked on consecutive days during the previous 72 hours by the bedside nurse who was caring for the patient at the time of hypoglycemia (case shift). For each case shift, we identified up to 3 control shifts (24, 48, and 72 hours before the hypoglycemic event in the same patient when there were no hypoglycemic events) and counted the number of consecutive shifts worked by those nurses in the previous 72 hours. This analysis allowed us to control for patient-associated confounders. Conditional logistic regression was used to determine the association between number of consecutive shifts worked and occurrence of hypoglycemic events. RESULTS: A total of 282 hypoglycemic events were identified in 259 patients. For 191 events, we were able to identify 1 or more control shifts. Compared with nurses who had not worked a shift in the preceding day, the odds ratio of a hypoglycemic event was 1.68 (95% confidence interval: 1.12-2.52), 2.16 (95% confidence interval:1.25-3.73), and 2.54 (95% confidence interval: 1.28-5.06) for nurses who were working their second, third, or fourth consecutive shift, respectively. CONCLUSIONS: Working multiple consecutive nursing shifts is associated with increased risk of hypoglycemic events in patients in an intensive care unit.

Effect of ambient workload in the intensive care unit on mortality and time to discharge alive.

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

Moral distress is associated with general workplace distress in intensive care unit personnel.

PURPOSE: To assess the association between moral distress and general workplace distress in intensive care unit (ICU) personnel. MATERIALS AND METHODS: We administered the Moral Distress Scale Revised and the Job Content Questionnaire to all clinicians (870 nurses, 68 physicians, 452 other health professionals) in 13 ICUs (3 tertiary, 3 large community, 7 small community) in British Columbia, Canada. We used mixed effects regression, treating ICUs as clusters, to examine the association between the Moral Distress Score and each Job Content Questionnaire scale (decision latitude, psychological stressors, social support, psychological strain) after adjusting for age, sex, and years of experience of respondents; separate analyses were done for each profession. RESULTS: Overall response rate was 45%. Nurses and other health professionals had higher moral distress scores than physicians, but there were no differences in general workplace distress scores among professional groups. After adjustment for demographic characteristics, higher moral distress in nurses was associated with lower decision latitude and social support, and with higher psychological stressors and psychological strain. For physicians and other professionals, these relationships were similar. CONCLUSIONS: Moral distress is associated with general workplace distress in ICU personnel. Interventions that ameliorate either type of distress may also ameliorate the other.

Moral distress in intensive care unit personnel is not consistently associated with adverse medication events and other adverse events.

PURPOSE: To examine the association between moral distress in ICU personnel, and medication errors and adverse events, and other adverse events. MATERIALS AND METHODS: In 13 ICUs, we measured moral distress once in all ICU staff, and incidence of five explicity-defined adverse safety events over 2 years. In 10 of the ICUs, pharmacists tabulated medication errors and adverse events during 1 day in the 2-year period. Average moral distress scores for each professional group were correlated with each safety measure. RESULTS: In the pharmacy study, there were almost no significant correlations between moral distress and measures of medication safety. However, higher moral distress in nurses was associated with more interceptions of near misses per administration error (r = 0.68, p = 0.04), and higher moral distress in physicians was associated with more incorrect measurements for medication monitoring per recommended action for monitoring (r = 0.68, p = 0.03). For the other adverse events, the only significant association was a positive association between moral distress in physicians and bleeding while on anticoagulants (OR: 1.1; 95% CI: 1.0-1.3). CONCLUSION: Moral distress in ICU personnel is generally not associated with medication errors or adverse events, or other adverse events, but it may be associated with both hyper-vigilance and distraction.