External validation of the ISARIC 4C Mortality Score to predict in-hospital mortality among patients with COVID-19 in a Canadian intensive care unit: a single-centre historical cohort study.

PURPOSE: With uncertain prognostic utility of existing predictive scoring systems for COVID-19-related illness, the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) 4C Mortality Score was developed by the International Severe Acute Respiratory and Emerging Infection Consortium as a COVID-19 mortality prediction tool. We sought to externally validate this score among critically ill patients admitted to an intensive care unit (ICU) with COVID-19 and compare its discrimination characteristics to that of the Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores. METHODS: We enrolled all consecutive patients admitted with COVID-19-associated respiratory failure between 5 March 2020 and 5 March 2022 to our university-affiliated and intensivist-staffed ICU (Jewish General Hospital, Montreal, QC, Canada). After data abstraction, our primary outcome of in-hospital mortality was evaluated with an objective of determining the discriminative properties of the ISARIC 4C Mortality Score, using the area under the curve of a logistic regression model. RESULTS: A total of 429 patients were included, 102 (23.8%) of whom died in hospital. The receiver operator curve of the ISARIC 4C Mortality Score had an area under the curve of 0.762 (95% confidence interval [CI], 0.717 to 0.811), whereas those of the SOFA and APACHE II scores were 0.705 (95% CI, 0.648 to 0.761) and 0.722 (95% CI, 0.667 to 0.777), respectively. CONCLUSIONS: The ISARIC 4C Mortality Score is a tool that had a good predictive performance for in-hospital mortality in a cohort of patients with COVID-19 admitted to an ICU for respiratory failure. Our results suggest a good external validity of the 4C score when applied to a more severely ill population.

RéSUMé: OBJECTIF: Compte tenu de l'utilité pronostique incertaine des systèmes de notation prédictive existants pour les maladies liées à la COVID-19, le score de mortalité ISARIC 4C a été mis au point par l'International Severe Acute Respiratory and Emerging Infection Consortium en tant qu'outil de prédiction de la mortalité associée à la COVID-19. Nous avons cherché à valider en externe ce score chez les patient·es gravement malades atteint·es de COVID-19 admis·es dans une unité de soins intensifs (USI) et à comparer ses caractéristiques de discrimination à celles des scores APACHE II (Acute Physiology and Chronic Health Evaluation) et SOFA (Sequential Organ Failure Assessment). MéTHODE: Nous avons recruté toutes les personnes consécutives admises pour insuffisance respiratoire associée à la COVID-19 entre le 5 mars 2020 et le 5 mars 2022 dans notre unité de soins intensifs affiliée à l'université et dotée d'intensivistes (Hôpital général juif, Montréal, QC, Canada). Après l'abstraction des données, notre critère d'évaluation principal de mortalité à l'hôpital a été évalué dans le but de déterminer les propriétés discriminatives du score de mortalité ISARIC 4C, en utilisant la surface sous la courbe d'un modèle de régression logistique. RéSULTATS: Au total, 429 patient·es ont été inclus·es, dont 102 (23,8 %) sont décédé·es à l'hôpital. La fonction d'efficacité du récepteur (courbe ROC) du score de mortalité ISARIC 4C avait une surface sous la courbe de 0,762 (intervalle de confiance [IC] à 95 %, 0,717 à 0,811), tandis que celles des scores SOFA et APACHE II étaient de 0,705 (IC 95%, 0,648 à 0,761) et 0,722 (IC 95%, 0,667 à 0,777), respectivement. CONCLUSION: Le score de mortalité ISARIC 4C est un outil qui a affiché une bonne performance prédictive de la mortalité à l'hôpital dans une cohorte de patient·es atteint·es de COVID-19 admis·es dans une unité de soins intensifs pour insuffisance respiratoire. Nos résultats suggèrent une bonne validité externe du score 4C lorsqu'il est appliqué à une population plus gravement malade.

High-flow nasal oxygen as first-line therapy for COVID-19-associated hypoxemic respiratory failure: a single-centre historical cohort study.

PURPOSE: The optimal noninvasive modality for oxygenation support in COVID-19-associated hypoxemic respiratory failure and its association with healthcare worker infection remain uncertain. We report here our experience using high-flow nasal oxygen (HFNO) as the primary support mode for patients with COVID-19 in our institution. METHODS: We conducted a single-centre historical cohort study of all COVID-19 patients treated with HFNO for at least two hours in our university-affiliated and intensivist-staffed intensive care unit (Jewish General Hospital, Montreal, QC, Canada) between 27 August 2020 and 30 April 2021. We report their clinical characteristics and outcomes. Healthcare workers in our unit cared for these patients in single negative pressure rooms wearing KN95 or fit-tested N95 masks; they underwent mandatory symptomatic screening for COVID-19 infection, as well as a period of asymptomatic screening. RESULTS: One hundred and forty-two patients were analysed, with a median [interquartile range (IQR)] age of 66 [59-73] yr; 71% were male. Patients had a median [IQR] Sequential Organ Failure Assessment Score of 3 [2-3], median [IQR] oxygen saturation by pulse oximetry/fraction of inspired oxygen ratio of 120 [94-164], and a median [IQR] 4C score (a COVID-19-specific mortality score) of 12 [10-14]. Endotracheal intubation occurred in 48/142 (34%) patients, and overall hospital mortality was 16%. Barotrauma occurred in 21/142 (15%) patients. Among 27 symptomatic and 139 asymptomatic screening tests, there were no cases of HFNO-related COVID-19 transmission to healthcare workers. CONCLUSION: Our experience indicates that HFNO is an effective first-line therapy for hypoxemic respiratory failure in COVID-19 patients, and can be safely used without significant discernable infection risk to healthcare workers.

RéSUMé: OBJECTIF: La modalité non invasive optimale pour le soutien en oxygène lors d'insuffisance respiratoire hypoxémique liée à la COVID-19 et son association avec l'infection des travailleurs de la santé restent incertaines. Nous rapportons ici notre expérience avec l'utilisation de canules nasales à haut débit (CNHD) comme principale modalité de soutien pour les patients atteints de COVID-19 dans notre établissement. MéTHODE: Nous avons mené une étude de cohorte historique monocentrique de tous les patients atteints de COVID-19 traités par CNHD pendant au moins deux heures dans notre unité de soins intensifs affiliée à l'université et dotée d'intensivistes (Hôpital général juif, Montréal, QC, Canada) entre le 27 août 2020 et le 30 avril 2021. Nous rapportons leurs caractéristiques cliniques et leurs résultats. Les travailleurs de la santé de notre unité ont soigné ces patients dans des chambres individuelles à pression négative en portant des masques KN95 ou N95 ajustés; ils ont subi un dépistage symptomatique obligatoire de l'infection à la COVID-19, ainsi qu'un dépistage en période asymptomatique. RéSULTATS: Cent quarante-deux patients ont été analysés, avec un âge médian [écart interquartile (ÉIQ)] de 66 [59-73] ans; 71 % étaient des hommes. Les patients avaient un score SOFA (Sequential Organ Failure Assessment) médian [ÉIQ] de 3 [2, 3], un ratio médian [ÉIQ] de saturation en oxygène par oxymétrie de pouls/fraction d'oxygène inspiré de 120 [94-164], et un score 4C (un score de mortalité spécifique à la COVID-19) médian [ÉIQ] de 12 [10­14]. Dans l'ensemble, 48/142 patients (34 %) ont reçu une intubation endotrachéale, et la mortalité hospitalière globale était de 16 %. Un barotraumatisme est survenu chez 21/142 (15 %) patients. Parmi les 27 tests de dépistage symptomatiques et 139 tests asymptomatiques, aucun cas de transmission de COVID-19 liée aux CNHD aux travailleurs de la santé n'a été observé. CONCLUSION: Notre expérience indique que les CNHD constituent un traitement de première intention efficace pour l'insuffisance respiratoire hypoxémique chez les patients atteints de COVID-19 qui peut être utilisé en toute sécurité, sans risque d'infection significatif discernable pour les travailleurs de la santé.

Implementing Advance Care Planning Tools in Practice: A Modified World Café to Elicit Barriers and Recommendations from Potential Adopters.

This paper reports findings from a modified World Café conducted at a palliative care professional conference in 2019, where input on tools to support advance care planning (ACP) was solicited from healthcare practitioners, managers and family members of patients. Barriers to ACP tool use included insufficient structures and resources in healthcare, death-avoidance culture and inadequate patient and family member engagement. Recommendations for tool use included clarification of roles and processes, training, mandates and monitoring, leadership support, greater reflection of diversity in tools and methods for public engagement. This paper illuminates factors to consider when implementing ACP tools in healthcare.

Interprofessional Survey of Perceived Barriers and Facilitators to Early Mobilization of Critically Ill Patients in Montreal, Canada.

OBJECTIVE: Early mobilization is safe, feasible, and associated with better outcomes in patients with critical illness. However, barriers to mobilization in clinical practice still exist. The objective of this study was to assess the knowledge and practice patterns of intensive care unit (ICU) clinicians, as well as the barriers and facilitators to early mobilization. DESIGN: Cross-sectional survey. SETTING: Intensive care units of 3 university-affiliated hospitals in Montreal, Canada. PARTICIPANTS: One hundred and thirty-eight ICU clinicians, including nurses, physicians, respiratory therapists, and physiotherapists. INTERVENTIONS: None. MEASUREMENTS: Perceived barriers, facilitators, knowledge, and practice patterns of early mobilization were assessed using a previously validated mobility survey tool. MAIN RESULTS: The overall response rate was 50.0% (138 of 274). Early mobilization was not perceived as a top priority in 49% of respondents. Results showed that clinicians were not fully aware of the benefits of early mobilization as per the current literature. About 58% of clinicians did not feel well trained and informed to mobilize mechanically ventilated patients. Perceptions on patient-level barriers varied with clinicians' professional training, but there was a high degree of interprofessional and intraprofessional disagreement on the permissible maximal level activity in different scenarios of critically ill patients. CONCLUSIONS: Our survey shows limited awareness, among our respondents, of the clinical benefits of early mobilization and high level of disagreement on the permissible maximal level of activity in the critically ill patients. Future studies should evaluate the role of knowledge translation in modifying these barriers and improving early mobilization.

Bioimpedance-measured volume overload predicts longer duration of mechanical ventilation in intensive care unit patients.

PURPOSE: Bioelectrical impedance analysis (BIA) is a technology that provides a rapid, non-invasive measurement of volume in body compartments and may aid the physician in the assessment of volume status. We sought to investigate the effect of BIA-measured volume status on duration of mechanical ventilation, 28-day mortality, and acute kidney injury requiring renal replacement therapy in a population of medical/surgical patients admitted to the intensive care unit (ICU). METHODS: Prospective observational study of adult patients who required mechanical ventilation within 24 hr of admission to ICU. Bioelectrical impedance analysis measured extracellular water (ECW) and total body water (TBW) and these measurements were recorded on days 1, 3, 5, and 7. RESULTS: A total of 36 patients were enrolled. Mean (standard deviation) age was 61.8 (21.3) years and 31% of patients were female. The majority were admitted from the emergency department or operating room. The most common diagnosis was sepsis. At 28 days, eight patients (22%) had died. There was no association between ECW/TBW ratio at day 1 and 28-day mortality (odds ratio, 1.2; 95% confidence interval [CI], 0.6 to 2.3) after adjusting for age, sex, and Acute Physiology and Chronic Health Evaluation II score. The median [interquartile range] number of ventilator days was 5 [2.5-7.5]. On day 1, for each 1% increase in the ECW/TBW ratio, there was a 1.2-fold increase in ventilator days (95% CI, 1.003 to 1.4; P = 0.05). It is notable that 20% of eligible patients could not be enrolled because medical equipment interfered with correct electrode placement. CONCLUSION: Bioimpedance-measured ECW/TBW on day 1 of admission to the ICU is associated with time on the ventilator. While this technology may be a useful adjunct to the clinical assessment of volume status, there are technical barriers to its routine use in a general ICU population.

Safety and Flight Considerations for Mechanical Circulatory Support Devices During Air Medical Transport and Evacuation: A Systematic Narrative Review of the Literature.

OBJECTIVE: The air medical transportation industry has seen a steady rise in the use of mechanical circulatory support devices (eg, intra-aortic balloon pumps, ventricular assist devices, and extracorporeal membrane oxygenation) during transport missions, either for definitive management or repatriation. As these complex devices become more common, the industry will have to adapt to support their use in their clientele. The goal of this narrative review was to assess our current experiences regarding mechanical circulatory support devices in air medical transportation and to identify important factors to ensure successful transport. METHODS: We conducted a systematic search on MEDLINE and Embase using the following search terms: aeromedical transportation, air transportation, intra-aortic balloon pump, ventricular assist device, and extracorporeal membrane oxygenation. Results were cross-referenced to identify articles addressing both air medical transport and mechanical circulatory support devices. RESULTS: After a systematic review of the available literature, 49 articles addressing mechanical support devices transported by rotary wing and fixed wing aircraft were reviewed. In summary, our review encompassed 811 total aerial transports (152 by balloon pumps, 12 by ventricular assist devices, and 647 by extracorporeal membrane oxygenation). We found air medical transportation with these devices carried out in the public, private, or military sectors, to be safe, with low rates of serious adverse events. Dedicated training sessions focused on device troubleshooting and problem-solving during transport, optimal medical crew composition, predeparture logistical preparations, and on-demand specialist consultation can improve mission success. CONCLUSION: We report that air medical transportation of patients supported by mechanical circulatory support devices is safe. Complications can be mitigated by training and addressed either during the predeparture or in-transportation phase.

Accuracy and generalizability of using automated methods for identifying adverse events from electronic health record data: a validation study protocol.

BACKGROUND: Adverse events (AEs) in acute care hospitals are frequent and associated with significant morbidity, mortality, and costs. Measuring AEs is necessary for quality improvement and benchmarking purposes, but current detection methods lack in accuracy, efficiency, and generalizability. The growing availability of electronic health records (EHR) and the development of natural language processing techniques for encoding narrative data offer an opportunity to develop potentially better methods. The purpose of this study is to determine the accuracy and generalizability of using automated methods for detecting three high-incidence and high-impact AEs from EHR data: a) hospital-acquired pneumonia, b) ventilator-associated event and, c) central line-associated bloodstream infection. METHODS: This validation study will be conducted among medical, surgical and ICU patients admitted between 2013 and 2016 to the Centre hospitalier universitaire de Sherbrooke (CHUS) and the McGill University Health Centre (MUHC), which has both French and English sites. A random 60% sample of CHUS patients will be used for model development purposes (cohort 1, development set). Using a random sample of these patients, a reference standard assessment of their medical chart will be performed. Multivariate logistic regression and the area under the curve (AUC) will be employed to iteratively develop and optimize three automated AE detection models (i.e., one per AE of interest) using EHR data from the CHUS. These models will then be validated on a random sample of the remaining 40% of CHUS patients (cohort 1, internal validation set) using chart review to assess accuracy. The most accurate models developed and validated at the CHUS will then be applied to EHR data from a random sample of patients admitted to the MUHC French site (cohort 2) and English site (cohort 3)-a critical requirement given the use of narrative data -, and accuracy will be assessed using chart review. Generalizability will be determined by comparing AUCs from cohorts 2 and 3 to those from cohort 1. DISCUSSION: This study will likely produce more accurate and efficient measures of AEs. These measures could be used to assess the incidence rates of AEs, evaluate the success of preventive interventions, or benchmark performance across hospitals.

The Impact of Implementation of an ICU Consult Service on Hospital-Wide Outcomes and ICU-Specific Outcomes.

BACKGROUND: Rapid response teams (RRTs) were developed to promote assessment of and early intervention for clinically deteriorating hospitalized patients. Although the ideal composition of RRTs is not known, their implementation does require significant resources. OBJECTIVE: To test the effectiveness of a dedicated daytime/weekday intensive care unit (ICU) consult service without formal training of ward teams. METHODS: Pre- and postintervention study with weekends/nights during implementation period acting as a concurrent control. SETTING: An adult tertiary care university center in Montreal without an RRT. INTERVENTION: A daytime/weekday ICU consult service with a dedicated intensivist. RESULTS: Total hospital mortality rate did not differ between the control and the implementation period (6.65% vs 6.60%; P = .84). The hospital code blue rates also did not differ (1.21/1000 vs 1.14/1000 patient days; P = .58). In contrast, 30-day mortality of patients admitted to the ICU following an ICU consult decreased (39% vs 24% P = .01). Multivariate analysis confirmed this effect on 30-day mortality (odds ratio for implementation period: 0.53 [95% confidence interval: 0.33-0.85] P = .009). The 14-day ICU readmission rate was reduced with the intervention (5.1% vs 4.1%; P < .001). The effect on 30-day mortality and ICU readmissions were only present during daytime/weekdays. CONCLUSION: Implementation of an ICU consult service without any formal afferent limb training was associated with decreased mortality and 14-day readmission rates of patients admitted to the ICU. In contrast, hospital-wide mortality and code blue rates were unaffected.

Antibiotic self-stewardship: trainee-led structured antibiotic time-outs to improve antimicrobial use.

BACKGROUND: Antibiotic use is an important quality improvement target. Nearly 50% of antibiotic use is unnecessary or inappropriate. To combat overuse, the Centers for Disease Control and Prevention (CDC) proposed "time-outs" to reevaluate antibiotics. OBJECTIVE: To optimize antibiotic use through trainee-led time-outs. DESIGN: Before-after study. SETTING: Internal medicine (2 units, 46 beds) at a university hospital. PATIENTS: Inpatients (n = 679). INTERVENTION: From January 2012 until June 2013, while receiving monthly education on antimicrobial stewardship, resident physicians adjusted patients' antibiotic therapy through twice-weekly time-out audits using a structured electronic checklist. MEASUREMENTS: Antibiotic costs were standardized and compared in the year before and after the audits. Use was measured as World Health Organization defined daily doses (DDDs) per 1000 patient-days. Total antibiotic use and the use of moxifloxacin, carbapenems, antipseudomonal penicillins, and vancomycin were compared by using interrupted time series. Rates of nosocomial Clostridium difficile infection were compared by using incidence rate ratios. RESULTS: Total costs in the units decreased from $149,743CAD (January 2011 to January 2012) to $80,319 (January 2012 to January 2013), for a savings of $69,424 (46% reduction). Of the savings, $54,150 (78%) was related to carbapenems and $15,274 (22%) was due to other antibiotic classes. Adherence with the auditing process was 80%. In the time-series analyses, the only reliable and statistically significant change was a reduction in the rate of moxifloxicin use, by -1.9 DDDs per 1000 patient-days per month (95% CI, -3.8 to -0.02; P = 0.048). Rates of C. difficile infection decreased from 24.2 to 19.6 per 10,000 patient-days (incidence rate ratio, 0.8 [CI, 0.5 to 1.3]). LIMITATION: Other temporal factors may confound the findings. CONCLUSIONS: An antibiotic self-stewardship bundle to implement the CDC's suggested time-outs seems to have reduced overall costs and targeted antibiotic use. PRIMARY FUNDING SOURCE: None.

Spontaneous, simultaneous bilateral osteonecrosis of the femoral heads in a patient with sideroblastic anaemia with B-cell immunodeficiency, periodic fever and developmental delay syndrome.

Sideroblastic anaemia with B-cell immunodeficiency, periodic fever and developmental delay is a recently described, rare syndrome characterised by numerous manifestations underpinned by mutations in transfer RNA nucleotidyltransferase. The pathogenesis arises from mitochondrial dysfunction, with impaired intracellular stress response, deficient metabolism and cellular and systemic inflammation. This yields multiorgan dysfunction and early death in many patients with survivors suffering significant disability and morbidity. New cases, often youths, are still being described, expanding the horizon of recognisable phenotypes. We present a mature patient with spontaneous bilateral hip osteonecrosis that likely arises from the impaired RNA quality control and inflammation caused by this syndrome.

Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial.

BACKGROUND: Awake prone positioning has been reported to improve oxygenation for patients with COVID-19 in retrospective and observational studies, but whether it improves patient-centred outcomes is unknown. We aimed to evaluate the efficacy of awake prone positioning to prevent intubation or death in patients with severe COVID-19 in a large-scale randomised trial. METHODS: In this prospective, a priori set up and defined, collaborative meta-trial of six randomised controlled open-label superiority trials, adults who required respiratory support with high-flow nasal cannula for acute hypoxaemic respiratory failure due to COVID-19 were randomly assigned to awake prone positioning or standard care. Hospitals from six countries were involved: Canada, France, Ireland, Mexico, USA, Spain. Patients or their care providers were not masked to allocated treatment. The primary composite outcome was treatment failure, defined as the proportion of patients intubated or dying within 28 days of enrolment. The six trials are registered with ClinicalTrials.gov, NCT04325906, NCT04347941, NCT04358939, NCT04395144, NCT04391140, and NCT04477655. FINDINGS: Between April 2, 2020 and Jan 26, 2021, 1126 patients were enrolled and randomly assigned to awake prone positioning (n=567) or standard care (n=559). 1121 patients (excluding five who withdrew from the study) were included in the intention-to-treat analysis. Treatment failure occurred in 223 (40%) of 564 patients assigned to awake prone positioning and in 257 (46%) of 557 patients assigned to standard care (relative risk 0·86 [95% CI 0·75-0·98]). The hazard ratio (HR) for intubation was 0·75 (0·62-0·91), and the HR for mortality was 0·87 (0·68-1·11) with awake prone positioning compared with standard care within 28 days of enrolment. The incidence of prespecified adverse events was low and similar in both groups. INTERPRETATION: Awake prone positioning of patients with hypoxaemic respiratory failure due to COVID-19 reduces the incidence of treatment failure and the need for intubation without any signal of harm. These results support routine awake prone positioning of patients with COVID-19 who require support with high-flow nasal cannula. FUNDING: Open AI inc, Rice Foundation, Projet Hospitalier de Recherche Clinique Interrégional, Appel d'Offre 2020, Groupement Interrégional de Recherche Clinique et d'Innovation Grand Ouest, Association pour la Promotion à Tours de la Réanimation Médicale, Fond de dotation du CHRU de Tours, Fisher & Paykel Healthcare Ltd.

Outcomes and clinical practice in patients with COVID-19 admitted to the intensive care unit in Montréal, Canada: a descriptive analysis.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic is responsible for millions of infections worldwide, and a substantial number of these patients will be admitted to the intensive care unit (ICU). Our objective was to describe the characteristics, outcomes and management of critically ill patients with COVID-19 pneumonia at a single designated pandemic centre in Montréal, Canada. METHODS: A descriptive analysis was performed on consecutive critically ill patients with COVID-19 pneumonia admitted to the ICU at the Jewish General Hospital, a designated pandemic centre in Montréal, between Mar. 5 and May 21, 2020. Complete follow-up data corresponding to death or discharge from hospital health records were included to Aug. 4, 2020. We summarized baseline characteristics, management and outcomes, including mortality. RESULTS: A total of 106 patients were included in this study. Twenty-one patients (19.8%) died during their hospital stay, and the ICU mortality was 17.0% (18/106); all patients were discharged home or died, except for 4 patients (2 awaiting a rehabilitation bed and 2 awaiting long-term care). Twelve of 65 patients (18.5%) requiring mechanical ventilation died. Prone positioning was used in 29 patients (27.4%), including in 10 patients who were spontaneously breathing; no patient was placed on extracorporeal membrane oxygenation. High-flow nasal cannula was used in 51 patients (48.1%). Acute kidney injury was the most common complication, seen in 20 patients (18.9%), and 12 patients (11.3%) required renal replacement therapy. A total of 53 patients (50.0%) received corticosteroids. INTERPRETATION: Our cohort of critically ill patients with COVID-19 had lower mortality than that previously described in other jurisdictions. These findings may help guide critical care decision-making in similar health care systems in further COVID-19 surges.

Supporting shared decision-making about cardiopulmonary resuscitation using a video-based decision-support intervention in a hospital setting: a multisite before-after pilot study.

BACKGROUND: Inpatients are often prescribed cardiopulmonary resuscitation (CPR) without a shared decision-making process. Since implementation of decision aids into practice is highly sensitive to the clinical milieu, we performed a pilot study to refine our study procedures and to evaluate the acceptability and potential effectiveness of a shared decision-making intervention when implemented in a Canadian hospital setting. METHODS: In this before-after pilot study, we recruited patients and family members on the medical wards of 2 Canadian teaching hospitals between September 2015 and March 2017. The intervention consisted of viewing a CPR decision video and completing a values-clarification worksheet; follow-up discussion with the physician was encouraged. The primary feasibility outcome was acceptability of the video, and the primary effectiveness outcome was change in the Decisional Conflict Scale score (lower scores being more desirable) after the intervention. Participants rated the extent of shared decision-making using the CollaboRATE instrument. RESULTS: Of the 71 participants (43 patients with a mean age of 79.0 [standard deviation (SD) 11.4] yr and 28 family members with a mean age of 61.0 [SD 10.0] yr), 65 (92%) rated the CPR decision video as good to excellent. The intervention was associated with an improvement in knowledge about CPR (+2.7 points, 95% confidence interval [CI] 2.2 to 3.3, effect size 1.5) and a reduction in the Decisional Conflict Scale score (-18.1 points, 95% CI -21.8 to -14.3, effect size 1.4). The 36 participants who had a discussion with a physician about CPR after watching the video rated the extent of shared decision-making as 6.3 (SD 1.7) (possible maximum score 9). There was a nonsignificant decrease in the proportion of patients with a medical order for CPR after the intervention (71% before v. 63% after, p = 0.06). INTERPRETATION: The CPR decision video was acceptable to patients and family members. Our decision-support intervention may improve knowledge, reduce decisional conflict and reduce the prevalence of medical orders for CPR in the Canadian hospital setting.

Validation of the Withdrawal Assessment Tool-1 in Adult Intensive Care Patients.

BACKGROUND: The Withdrawal Assessment Tool-1 (WAT-1) has been validated for assessing iatrogenic withdrawal syndrome in critically ill children receiving mechanical ventilation, but little is known about this syndrome in critically ill adults. OBJECTIVE: To evaluate the validity and reliability of the WAT-1 in critically ill adults. METHODS: A prospective, observational, open-cohort pilot study of critically ill adults receiving mechanical ventilation and regular administration of opioids for at least 72 hours. Patients were assessed for withdrawal twice daily on weekdays and once daily on weekends using the WAT-1 after an opioid weaning episode. The presence of iatrogenic withdrawal syndrome was evaluated once daily using modified Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) criteria. All evaluations were blinded and performed independently. The criterion validity of the WAT-1 and the interrater reliability for WAT-1 and DSM-5 evaluations were determined. RESULTS: During 8 months, 52 adults (median age, 51.5 years) were enrolled. Eight patients (15%) had at least 1 positive assessment during their intensive care unit stay using the DSM-5, compared with 19 patients (37%) using the WAT-1. The overall sensitivity of the WAT-1 was 50%, and its specificity was 65.9%. Agreement between WAT-1 and DSM-5 assessments was poor (κ = 0.102). The interrater reliability for the WAT-1 was 89.1% and for the DSM-5 was 90.1%. CONCLUSION: Despite showing reliability, the WAT-1 is not a valid tool for assessing the presence of iatrogenic withdrawal syndrome in adults.

Duration of corticosteroid use in chronic obstructive pulmonary disease exacerbations: improving prescribing practices on clinical teaching units with peer-to-peer teaching.

INTRODUCTION: The most recent Global Initiative for Chronic Obstructive Lung Disease consensus recommends a 5-day course of corticosteroid (CS) therapy for acute chronic obstructive pulmonary disease exacerbations (ACOPDE). As inappropriate use of CS therapy is associated with adverse events, we implemented a peer-to-peer education intervention to improve adherence to guidelines for patients with ACOPDE admitted to a medical clinical teaching unit at a tertiary care university centre. METHODS: Our study was a before-after design study with a concurrent control of a 15 min peer-to-peer educational intervention targeting medical residents at the beginning of a 4-week rotation for 12 consecutive months. Another medical teaching unit within the same university network, but at a different site, served as a concurrent control. The primary outcome was the proportion of patients who received appropriate duration of CS therapy (5 days) for ACOPDE during the intervention period as compared with the 12-month preintervention period at the intervention and control hospitals. RESULTS: Following the intervention, there was an increase in the proportion of patients receiving appropriate duration of CS therapy (34.2% to 51.3%, p=0.02) at the intervention hospital and no significant difference at the control hospital (22.8% to 34.1%, p=0.15). This effect was maintained at the intervention hospital 3 months postintervention period. CONCLUSION: A short peer-to-peer educational intervention targeting medical residents on a clinical teaching unit improved adherence to appropriate duration of CS therapy for ACOPDE.

Serial lung and IVC ultrasound in the assessment of congestive heart failure.

BACKGROUND: Management of congestive heart failure (CHF) is dependent on clinical assessments of volume status, which are subjective and imprecise. Point-of-care ultrasound (POCUS) is useful in the diagnosis of CHF, but how POCUS findings correlate with therapy remains unknown. This study aimed to determine whether the changes in clinical evaluation of CHF with treatment are mirrored with changes in the number of B lines on lung ultrasound (LUS) and inferior vena cava (IVC) size. In this prospective observational study, investigators performed serial clinical and ultrasound assessments within 24 h of admission (T1), day 1 in hospital (T2) and within 24 h of discharge (T3). Clinical assessments included an evaluation of the jugular venous distension (JVD), hepatojugular reflux (HJR), pulmonary rales and a clinical congestion score was calculated. Ultrasound assessment included the IVC size and collapsibility, and the number of B lines in an 8-point scan. RESULTS: Fifty consecutive patients were recruited with a mean age of 71.2 years (SD 12.7). Mean clinical congestion score on admission was 5.6 (SD 1.4) and declined significantly over time to 1.3 (0.91), as did the JVP, HJR and pulmonary rales. No significant changes were found in the IVC size between T1 [1.9 (0.65)] and T3 [2.0 (0.50)] or in the IVC collapsibility index [T1 0.3 (0.19) versus T3 0.25 (0.16)]. The mean number of B lines decreased from 11 (6.1) at T1 to 8.3 (5.5) at T3, although this decrease did not reach statistical significance. Spearman correlation between JVP and HJR versus IVC collapsibility and total B lines did not yield significant results. CONCLUSIONS: Clinical exam findings correlate over time during the management of CHF, whereas LUS and IVC results did not. The number of B lines did decrease with therapy, but did not reach statistical significance likely because the sampled population was small and had only mild heart failure. Further studies are warranted to further explore the use of lung ultrasound in this patient population.

Opioid-associated iatrogenic withdrawal in critically ill adult patients: a multicenter prospective observational study.

BACKGROUND: Opioids and benzodiazepines are frequently used in the intensive care unit (ICU). Regular use and prolonged exposure to opioids in ICU patients followed by abrupt tapering or cessation may lead to iatrogenic withdrawal syndrome (IWS). IWS is well described in pediatrics, but no prospective study has evaluated this syndrome in adult ICU patients. The objective of this study was to determine the incidence of IWS caused by opioids in a critically ill adult population. This multicenter prospective cohort study was conducted at two level-1 trauma ICUs between February 2015 and September 2015 and included 54 critically ill patients. Participants were eligible if they were 18 years and older, mechanically ventilated and had received more than 72 h of regular intermittent or continuous intravenous infusion of opioids. For each enrolled patient and per each opioid weaning episode, presence of IWS was assessed by a qualified ICU physician or senior resident according to the 5th edition of Diagnostic and Statistical Manual of Mental Disorders criteria for opioid withdrawal. RESULTS: The population consisted mostly of males (74.1%) with a median age of 50 years (25th-75th percentile 38.2-64.5). The median ICU admission APACHE II score was 22 (25th-75th percentile 12.0-28.2). The overall incidence of IWS was 16.7% (95% CI 6-27). The median cumulative opioid dose prior to weaning was higher in patients with IWS (245.7 vs. 169.4 mcg/kg, fentanyl equivalent). Patients with IWS were also exposed to opioids for a longer period of time as compared to patients without IWS (median 151 vs. 125 h). However, these results were not statistically significant. CONCLUSIONS: IWS was occasionally observed in this very specific population of mechanically ventilated, critically ill ICU patients. Further studies are needed to confirm these preliminary results and identify risk factors.

Impact of a Local Low-Cost Ward-Based Response System in a Canadian Tertiary Care Hospital.

Background. Medical emergency teams (METs) or rapid response teams (RRTs) facilitate early intervention for clinically deteriorating hospitalized patients. In healthcare systems where financial resources and intensivist availability are limited, the establishment of such teams can prove challenging. Objectives. A low-cost, ward-based response system was implemented on a medical clinical teaching unit in a Montreal tertiary care hospital. A prospective before/after study was undertaken to examine the system's impact on time to intervention, code blue rates, and ICU transfer rates. Results. Ninety-five calls were placed for 82 patients. Median time from patient decompensation to intervention was 5 min (IQR 1-10), compared to 3.4 hours (IQR 0.6-12.4) before system implementation (p < 0.001). Total number of ICU admissions from the CTU was reduced from 4.8/1000 patient days (±2.2) before intervention to 3.3/1000 patient days (±1.4) after intervention (IRR: 0.82, p = 0.04 (CI 95%: 0.69-0.99)). CTU code blue rates decreased from 2.2/1000 patient days (±1.6) before intervention to 1.2/1000 patient days (±1.3) after intervention (IRR: 0.51, p = 0.02 (CI 95%: 0.30-0.89)). Conclusion. Our local ward-based response system achieved a significant reduction in the time of patient decompensation to initial intervention, in CTU code blue rates, and in CTU to ICU transfers without necessitating additional usage of financial or human resources.

The Perceived Likelihood of Outcome of Critical Care Patients and Its Impact on Triage Decisions: A Case-Based Survey of Intensivists and Internists in a Canadian, Quaternary Care Hospital Network.

INTRODUCTION: There is high variability amongst physicians' assessments of appropriate ICU admissions, which may be based on potential assessments of benefit. We aimed to examine whether opinions over benefit of ICU admissions of critically ill medical inpatients differed based on physician specialty, namely intensivists and internists. MATERIALS AND METHODS: We carried out an anonymous, web-based questionnaire survey containing 5 typical ICU cases to all ICU physicians regardless of their base specialty as well as to all internists in 3 large teaching hospitals. For each case, we asked the participants to determine if the patient was an appropriate ICU admission and to assess different parameters (e.g. baseline function, likelihood of survival to ICU discharge, etc.). Agreement was measured using kappa values. RESULTS: 21 intensivists and 22 internists filled out the survey (response rate = 87.5% and 35% respectively). Predictions of likelihood of survival to ICU admission, hospital discharge and return to baseline were not significantly different between the two groups. However, agreement between individuals within each group was only slight to fair (kappa range = 0.09-0.22). There was no statistically significant difference in predicting ICU survival and prediction of survival to hospital discharge between both groups. The accuracy with which physicians predicted actual outcomes ranged between 35% and 100% and did not significantly differ between the two groups. A greater proportion of internists favoured non resuscitative measures (24.6% of intensivists and 46.9% internists [p = 0.002]). CONCLUSION: In a case-based survey, physician specialty base did not affect assessments of ICU admission benefit or accuracy in outcome prediction, but resulted in a statistically significant difference in level of care assignments. Of note, significant disagreement amongst individuals in each group was found.

Early left ventricular ejection fraction as a predictor of survival after cardiac arrest.

BACKGROUND: Cardiopulmonary resuscitation and early defibrillation have been shown to improve outcomes of cardiac arrest. The significance of the post-arrest echocardiogram, specifically the left ventricular ejection fraction (LVEF) is unknown. METHODS: We performed a retrospective cohort study of patients who suffered from cardiac arrest between 1 January 2009 and 31 December 2013. We included all patients who achieved return of spontaneous circulation (ROSC), and were admitted to the intensive care unit (ICU) or coronary care unit (CCU) of a tertiary care academic center. Patients who underwent echocardiography within 24 h of cardiac arrest were included for analysis. The primary outcome was survival. RESULTS: We identified 151 patients who achieved ROSC of which 97 underwent post-arrest echocardiogram within 24 h. 70.8% were males and the mean age was 67.8 years (SD: 15.9). The mean LVEF at 24 h was 35.7 (SD: 17.8). LVEF > 40% was not a predictor of survival at 30 days or hospital discharge. The only significant predictors on multivariate analyses were age, presence of shockable rhythm and time to ROSC. CONCLUSION: Although echocardiograms are frequently ordered, LVEF greater than 40% in patients who are resuscitated after a cardiac arrest is not a predictor of survival.