User-Centered Development of a Patient Decision Aid for Choice of Early Abortion Method: Multi-Cycle Mixed Methods Study.

BACKGROUND: People seeking abortion in early pregnancy have the choice between medication and procedural options for care. The choice is preference-sensitive-there is no clinically superior option and the choice depends on what matters most to the individual patient. Patient decision aids (PtDAs) are shared decision-making tools that support people in making informed, values-aligned health care choices. OBJECTIVE: We aimed to develop and evaluate the usability of a web-based PtDA for the Canadian context, where abortion care is publicly funded and available without legal restriction. METHODS: We used a systematic, user-centered design approach guided by principles of integrated knowledge translation. We first developed a prototype using available evidence for abortion seekers' decisional needs and the risks, benefits, and consequences of each option. We then refined the prototype through think-aloud interviews with participants at risk of unintended pregnancy ("patient" participants). Interviews were audio-recorded and documented through field notes. Finally, we conducted a web-based survey of patients and health care professionals involved with abortion care, which included the System Usability Scale. We used content analysis to identify usability issues described in the field notes and open-ended survey questions, and descriptive statistics to summarize participant characteristics and close-ended survey responses. RESULTS: A total of 61 individuals participated in this study. Further, 11 patients participated in think-aloud interviews. Overall, the response to the PtDA was positive; however, the content analysis identified issues related to the design, language, and information about the process and experience of obtaining abortion care. In response, we adapted the PtDA into an interactive website and revised it to include consistent and plain language, additional information (eg, pain experience narratives), and links to additional resources on how to find an abortion health care professional. In total, 25 patients and 25 health care professionals completed the survey. The mean System Usability Scale score met the threshold for good usability among both patient and health care professional participants. Most participants felt that the PtDA was user-friendly (patients: n=25, 100%; health care professionals: n=22, 88%), was not missing information (patients: n=21, 84%; health care professionals: n=18, 72%), and that it was appropriate for patients to complete the PtDA before a consultation (patients: n=23, 92%; health care professionals: n=23, 92%). Open-ended responses focused on improving usability by reducing the length of the PtDA and making the website more mobile-friendly. CONCLUSIONS: We systematically designed the PtDA to address an unmet need to support informed, values-aligned decision-making about the method of abortion. The design process responded to a need identified by potential users and addressed unique sensitivities related to reproductive health decision-making.

Characterization of Opioid Use in the Intensive Care Unit and Its Impact Across Care Transitions: A Prospective Study.

PURPOSE: The objective of this study is to characterize opioid intensity in the intensive care unit (ICU) and its association with opioid utilization across care transitions. METHODS: This is a prospective cohort study. Medically ill ICU patients with complete medication histories who survived to discharge were included. Opioid intensity was characterized based on IV morphine milligram equivalents (IV MME). Primary outcomes were opioid prescribing upon ICU and hospital discharge. RESULTS: Opioids were prescribed to 34.1% and 31.1% of patients upon ICU and hospital discharge. Within the ≥50 mean IV MME/ICU day cohort, 64.7% of patients received opioids after ICU discharge compared to 45.8% and 13.6% in the 1-49 mean IV MME/ICU day and no opioid groups (P < .05). Within the ≥50 mean IV MME/ICU day cohort, 70.6% of patients were prescribed opioids after hospitalization compared to 37.3% and 13.6% of patients who received less or no opioids. (P < .05). Within the ≥50 mean IV MME/ICU day cohort, 29.4% of patients were opioid naïve and discharged with an opioid, which is over double compared to patients with lower opioid requirements (P < .05). CONCLUSION: Patients with higher mean daily ICU opioid requirements had increased opioid prescribing across care transitions despite preadmission opioid use.

Ketamine in Critically Ill Patients: Use, Perceptions, and Potential Barriers.

Objective: To evaluate practitioner use of ketamine and identify potential barriers to use in acutely and critically ill patients. To compare characteristics, beliefs, and practices of ketamine frequent users and non-users. Methods: An online survey developed by members of the Society of Critical Care Medicine (SCCM) Clinical Pharmacy and Pharmacology Section was distributed to physician, pharmacist, nurse practitioner, physician assistant and nurse members of SCCM. The online survey queried SCCM members on self-reported practices regarding ketamine use and potential barriers in acute and critically ill patients. Results: Respondents, 341 analyzed, were mostly adult physicians, practicing in the United States at academic medical centers. Clinicians were comfortable or very comfortable using ketamine to facilitate intubation (80.0%), for analgesia (77.9%), procedural sedation (79.4%), continuous ICU sedation (65.8%), dressing changes (62.4%), or for asthma exacerbation and status epilepticus (58.8% and 40.4%). Clinicians were least comfortable with ketamine use for alcohol withdrawal and opioid detoxification (24.7% and 23.2%). Most respondents reported "never" or "infrequently" using ketamine preferentially for continuous IV analgesia (55.6%) or sedation (61%). Responses were mixed across dosing ranges and duration. The most common barriers to ketamine use were adverse effects (42.6%), other practitioners not routinely using the medication (41.5%), lack of evidence (33.5%), lack of familiarity (33.1%), and hospital/institutional policy guiding the indication for use (32.3%). Conclusion: Although most critical care practitioners report feeling comfortable using ketamine, there are many inconsistencies in practice regarding dose, duration, and reasons to avoid or limit ketamine use. Further educational tools may be targeted at practitioners to improve appropriate ketamine use.

Review of Hematological and Oncological Emergencies.

Patients with hematological malignancies, both treated and untreated, or solid tumors undergoing treatment are at risk of life-threatening complications, which may present in the emergency department (ED). Such emergencies are diverse in etiology and often require prompt treatment. Traditional complications, such as febrile neutropenia, have had recent guideline updates, which incorporate new evidence and a new validated risk stratification tool. In addition, newer approaches to treatment, such as chimeric antigen receptor (CAR) T-cell therapy, are becoming more widely available and have unique associated toxicities. This review discusses the management of the following hematological and oncological emergencies likely to be encountered in the ED: febrile neutropenia, CAR T-cell toxicities, differentiation syndrome, tumor lysis syndrome, hypercalcemia of malignancy, and hyponatremia.

Development and implementation of a clinical decision support-based initiative to drive intravenous fluid prescribing.

OBJECTIVE: Studies suggest superior outcomes with use of intravenous (IV) balanced fluids compared to normal saline (NS). However, significant fluid prescribing variability persists, highlighting the knowledge-to-practice gap. We sought to identify contributors to prescribing variation and utilize a clinical decision support system (CDSS) to increase institutional balanced fluid prescribing. MATERIALS AND METHODS: This single-center informatics-enabled quality improvement initiative for patients hospitalized or treated in the emergency department included stepwise interventions of 1) identification of design factors within the computerized provider order entry (CPOE) of our electronic health record (EHR) that contribute to preferential NS ordering, 2) clinician education, 3) fluid stocking modifications, 4) re-design and implementation of a CDSS-integrated IV fluid ordering panel, and 5) comparison of fluid prescribing before and after the intervention. EHR-derived prescribing data was analyzed via single interrupted time series. RESULTS: Pre-intervention (3/2019-9/2019), balanced fluids comprised 33% of isotonic fluid orders, with gradual uptake (1.4%/month) of balanced fluid prescribing. Clinician education (10/2019-2/2020) yielded a modest (4.4%/month, 95% CI 1.6-7.2, p = 0.01) proportional increase in balanced fluid prescribing, while CPOE redesign (3/2020) yielded an immediate (20.7%, 95% CI 17.7-23.6, p < 0.0001) and sustained increase (72% of fluid orders in 12/2020). The intervention proved most effective among those with lower baseline balanced fluids utilization, including emergency medicine (57% increase, 95% CI 0.7-1.8, p < 0.0001) and internal medicine/subspecialties (18% increase, 95% CI 14.4-21.3, p < 0.0001) clinicians and substantially reduced institutional prescribing variation. CONCLUSION: Integration of CDSS into an EHR yielded a robust and sustained increase in balanced fluid prescribing. This impact far exceeded that of clinician education highlighting the importance of CDSS.

Vitamin C for Sepsis and Septic Shock.

BACKGROUND: Sepsis remains a leading cause of death in the critically ill. The combination of thiamine, vitamin C, and hydrocortisone has recently emerged as a potential adjunctive therapy and supportive care for patients with sepsis and septic shock. AREAS OF UNCERTAINTY: Several randomized and observational controlled trials evaluated the role of vitamin C in sepsis and septic shock. However, there are variabilities in the findings of these studies that led to a substantial global debate on incorporating vitamin C therapy in clinical practice. DATA SOURCES: A PubMed and Embase English language literature search through April 2021 was performed using the following terms: ascorbic acid, vitamin C, corticosteroid, hydrocortisone, thiamine, HAT, sepsis, and shock. Citations, including controlled trials, observational studies, review articles, guidelines, and consensus statements, were reviewed. The risk of bias for each clinical study was systematically evaluated. Relevant clinical data focusing on efficacy, safety, and special considerations regarding the use of vitamin C with and without thiamine and hydrocortisone in sepsis and septic shock were narratively summarized. RESULTS: The most commonly used vitamin C dosing in sepsis and septic shock is 1.5 g every 6 hours with and without thiamine and hydrocortisone. Current literature is limited because of heterogeneity in vitamin C regimen used, initiation time, and duration of treatment. This limitation led to variability in outcomes evaluated. Vitamin C decreases proinflammatory mediators and slows the progression of endothelial injury in severe sepsis. There is an inconsistency between randomized controlled trials and observational controlled trials regarding mortality, resolution in organ failure, hospital and intensive care unit length of stay findings with the use of vitamin C in septic shock. Vitamin C seems to be safe in comparison with placebo. CONCLUSIONS: Future studies with consistent end points, initiation time with an emphasis on early initiation, and standard vitamin C dosing regimen are needed to determine the overall benefit of vitamin C in sepsis.

Stapled versus hand-sewn pediatric intestinal anastomoses: A retrospective cohort study.

BACKGROUND: Whereas the adult literature has demonstrated the acceptable safety profile of stapled anastomoses when compared to the hand-sewn alternative, the choice of intestinal anastomosis using sutures or staples remains inadequately investigated in children. The purpose of this study is to compare the anastomotic outcomes of both techniques in children under 5years of age. METHODS: A retrospective analysis of patients undergoing intestinal anastomosis at a single tertiary centre (2012-2016) was undertaken. Demographics, diagnosis, anatomy, and complications were compared between the hand-sewn (HS) and stapled anastomosis (SA) groups. Primary outcomes were anastomotic leak and/or stricture requiring intervention. RESULTS: There were 72 patients with 90 intestinal anastomoses (67 HS, 23 SA). Baseline demographics between the two anastomotic groups were comparable. The overall anastomotic complication rate was 23.9% (HS) and 17.4% (SA). In the ileocolic subgroup, anastomotic complications occurred in 3/7 HS vs. 0/5 SA (ns). There were no statistically significant differences in primary outcomes between HS and SA. All SA complications occurred with 3.5 or 3.8mm staples. CONCLUSIONS: In our study population, no statistically significant difference between hand-sewn and stapled intestinal anastomosis outcomes was found. However, further investigation is warranted. LEVEL OF EVIDENCE: 3 (Retrospective Comparative Treatment Study).

Nucleotide sequence-based typing of meningococci directly from clinical samples.

The unpredictable characteristics of meningococcal disease (MD) make outbreaks complicated to monitor and consequently lead to high levels of public anxiety. Traditional molecular techniques have been utilized in order to understand better the epidemiology of MD, but some have disadvantages such as being highly specialized and labour-intensive, with low reproducibility. Some of these problems have been overcome by using multilocus sequence typing (MLST). This technique exploits the unambiguous nature and electronic portability of nucleotide sequencing data for the characterization of micro-organisms. The need for enhanced surveillance of MD after the introduction of serogroup C conjugate vaccines means that it is important to gain typing information from the infecting organism in the absence of a culture isolate. Here, the application of MLST for the laboratory confirmation and characterization of Neisseria meningitidis directly from clinical samples is described. This involved using a newly designed set of primers that were complementary to nucleotide sequences external to the existing MLST primers already in use for culture-based MLST of meningococci. This combination has produced a highly sensitive procedure to allow the efficient genotypic characterization of meningococci directly from clinical samples.