A systematic review and critical appraisal of guidelines and their recommendations for sedation interruptions in adult mechanically ventilated patients.

OBJECTIVE: The objectives of the review were to (i) assess the methodological quality of all accessible and published guidelines and care bundles that offer a recommendation related to sedation interruptions, using the AGREE-II instrument, to (ii) determine what is the recommended best practice for sedation interruptions from the available guidelines, and then to have (iii) a closer inspection of the overall credibility and applicability of the recommendations using the AGREE-REX instrument. This review will benefit the outcomes of critically ill patients and the multidisciplinary team responsible for the care of mechanically ventilated adults with continuous medication infusions by providing a synthesis of the recommended action(s), actor(s), contextual information, target(s), and timing related to sedation interruptions from current best practice. REVIEW METHOD USED: We conducted a systematic review. DATA SOURCES: We applied a peer-reviewed search strategy to four electronic databases from 2010 to November 2021-MEDLINE, CINAHL, Embase, and The Cochrane Database of Systematic Reviews-and included grey literature. REVIEW METHOD: Findings are reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses checklist. We assessed overall quality using the validated Appraisal of Guidelines for Research and Evaluation II and AGREE Recommendation Excellence tools. RESULTS: We identified 11 clinical practice guidelines and care bundles comprising 15 recommendations related to sedation interruption. There are three key findings: (i) deficiencies exist with the methodological quality of included guidelines, (ii) sedation interruption is recommended practice for the care of adult mechanically ventilated patients, and (iii) the current evidence is of low quality, which impacts overall credibility and applicability of the recommendations. CONCLUSIONS: Sedation interruptions are currently best practice for adult mechanically ventilated patients; however, the available guidelines and recommendations have several deficiencies. Future research is needed to further understand the role of the nurse and other actors to enact this practice.

Inappropriate use of clinical practices in Canada: a systematic review.

BACKGROUND: Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada. METHODS: We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level. RESULTS: We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%-56.6%). Underuse (median 43.9%, IQR 23.8%-66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%-30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%-85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%-35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%-71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%-97.3%, n = 9). INTERPRETATION: We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

Trainee-led research using an integrated knowledge translation or other research partnership approaches: a scoping reviews.

BACKGROUND: There are increasing expectations for researchers and knowledge users in the health system to use a research partnership approach, such as integrated knowledge translation, to increase the relevance and use of research findings in health practice, programmes and policies. However, little is known about how health research trainees engage in research partnership approaches such as IKT. In response, the purpose of this scoping review was to map and characterize the evidence related to using an IKT or other research partnership approach from the perspective of health research trainees in thesis and/or postdoctoral work. METHODS: We conducted this scoping review following the Joanna Briggs Institute methodology and Arksey and O'Malley's framework. We searched the following databases in June 2020: MEDLINE, Embase, CINAHL and PsycINFO. We also searched sources of unpublished studies and grey literature. We reported our findings in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. RESULTS: We included 74 records that described trainees' experiences using an IKT or other research partnership approach to health research. The majority of studies involved collaboration with knowledge users in the research question development, recruitment and data collection stages of the research process. Intersecting barriers to IKT or other research partnerships at the individual, interpersonal and organizational levels were reported, including lack of skills in partnership research, competing priorities and trainees' "outsider" status. We also identified studies that evaluated their IKT approach and reported impacts on partnership formation, such as valuing different perspectives, and enhanced relevance of research. CONCLUSION: Our review provides insights for trainees interested in IKT or other research partnership approaches and offers guidance on how to apply an IKT approach to their research. The review findings can serve as a basis for future reviews and primary research focused on IKT principles, strategies and evaluation. The findings can also inform IKT training efforts such as guideline development and academic programme development.

To whom health care aides report: Effect on nursing home resident outcomes.

INTRODUCTION: Health care aides (personal support workers and nursing assistants) provide ~80%-90% of direct care to residents in nursing homes; it is therefore important to understand whether supervision of health care aides affects quality of care. We sought to determine whether health care aide reporting practices are associated with resident outcomes in nursing homes. DESIGN AND METHODS: We conducted a cross-sectional secondary analysis of survey data of 3991 health care aides from 322 units in 89 nursing homes in Western Canada. We then linked resident data from the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0 database to care aide surveys at the unit level. We used hierarchical mixed models to determine if the proportion of health care aides reporting to a respective nursing leader role was associated with 13 practice sensitive quality indicators of resident care. RESULTS: Most health care aides reported to a registered nurse (RN, 44.5%) or licenced practical nurse (LPN, 53.3%). Only 2.2% of health care aides reported to a care manager and were excluded from the analysis. Resident outcomes for only declining behavioural symptoms were more favourable when a higher proportion of health care aides (on a unit) reported to RNs, ß = -0.004 (95% CI -0.006, -0.001, p = .004). The remaining indicators were not affected by care aide reporting practices. DISCUSSION AND IMPLICATIONS: Resident outcomes as evaluated by the indicators appear largely unaffected by care aide reporting practices. LPNs' increasing scope of practice and changing work roles and responsibilities in nursing homes across Western Canada may explain the findings.

Behavioral Determinants of Canadian Radiation Oncologists' Use of Single Fraction Palliative Radiation Therapy for Uncomplicated Bone Metastases.

BACKGROUND: A mainstay therapy for pain relief from uncomplicated bone metastases is external beam radiation therapy. Single fraction radiation therapy (SFRT) is more convenient and cost-effective, causes fewer acute side effects, and is equivalent to multiple fraction radiation therapy for pain relief. Despite these advantages, radiation oncologists seldom prescribe SFRT. PURPOSE: To identify the behavioral determinants to Canadian radiation oncologists' use of SFRT for uncomplicated bone metastases. METHODS AND MATERIALS: Semistructured interviews were conducted with 38 radiation oncologists from all 10 Canadian provinces. The interview guide and analysis were guided by the Theoretical Domains Framework (TDF). Transcripts were analyzed using a 5-phase thematic content analysis process: coding, generation of belief statements, generation of themes within TDF domains, generation of overarching themes, and classification of themes as barriers or facilitators to SFRT use, or as divergent (a barrier or facilitator depending on the participant). RESULTS: Thirteen overarching themes were identified of which 2 were barriers, 7 were facilitators, and 4 were divergent. The most commonly identified theme was the facilitator "most radiation oncologists are aware of evidence and guidelines on the use SFRT" (n = 38, 100%). The 3 next most reported themes (n = 37, 97.4% ) were (1) "radiation oncologists' use of SFRT can influence their colleagues" use of it (divergent), (2) experience with SFRT can increase its use (facilitator), and (3) SFRT is convenient for patients (facilitator). The most commonly identified barrier (n = 31, 81.6%) was "SFRT is associated with a higher risk of retreatment." CONCLUSIONS: Our use of the TDF to explore the behavioral determinants of Canadian radiation oncologists' use of SFRT for uncomplicated bone metastases identified a range of factors that are perceived to encourage and discourage its use. Our results will inform the design of future interventions to increase the use of SFRT.