Showing papers by "Deborah J. Cook published in 2004"
TL;DR: The methods used to create the VAP Prevention Guideline Panel, an evidence-based clinical practice guideline for the prevention of VAP, and the recommendations generated are described.
Abstract: This article describes an evidence-based clinical practice guideline for preventing ventilator-associated pneumonia.
482 citations
TL;DR: Stepwise logistic regression analysis showed that elevated Acute Physiology and Chronic Health Evaluation II score, gram-negative infection, and emergency admission status were independent predictors of EA.
Abstract: A novel assay for endotoxin, based on the ability of antigen-antibody complexes to prime neutrophils for an augmented respiratory burst response, was studied in a cohort study of 857 patients admitted to an intensive-care unit (ICU). On the day of ICU admission, 57.2% of patients had either intermediate (>or=0.40 endotoxin activity [EA] units) or high (>or=0.60 units) EA levels. Gram-negative infection was present in 1.4% of patients with low EA levels, 4.9% with intermediate levels, and 6.9% with high levels; EA had a sensitivity of 85.3% and a specificity of 44.0% for the diagnosis of gram-negative infection. Rates of severe sepsis were 4.9%, 9.2%, and 13.2%, and ICU mortality was 10.9%, 13.2%, and 16.8% for patients with low, intermediate, and high EA levels, respectively. Stepwise logistic regression analysis showed that elevated Acute Physiology and Chronic Health Evaluation II score, gram-negative infection, and emergency admission status were independent predictors of EA.
311 citations
TL;DR: In this article, a spectrum of disease ranging from a mild, self-limited course requiring only brief hospitalization to a rapidly progressive, fulminant illness resulting in the multiple organ dysfunction syndrome (MODS), with or without accompanying sepsis.
Abstract: Objective:Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course requiring only brief hospitalization to a rapidly progressive, fulminant illness resulting in the multiple organ dysfunction syndrome (MODS), with or without accompanying sepsis. The goal of this c
295 citations
TL;DR: These studies suggest that patients who are perceived not to benefit from critical care are more often refused intensive care unit admission; refusal is associated with an increased risk of hospital death.
Abstract: Objective:Rationing critical care beds occurs daily in the hospital setting. The objective of this systematic review was to examine the impact of rationing intensive care unit beds on the process and outcomes of care.Data Source:We searched MEDLINE (1966–2003), CINAHL (1982–2003), Ovid Healthstar (1
285 citations
TL;DR: Physician estimates of intensive care unit survival <10% are associated with subsequent life support limitation and more powerfully predictintensive care unit mortality than illness severity, evolving or resolving organ dysfunction, and use of inotropes or vasopressors.
Abstract: Objective:Predicting outcomes for critically ill patients is an important aspect of discussions with families in the intensive care unit. Our objective was to evaluate clinical intensive care unit survival predictions and their consequences for mechanically ventilated patients.Design:Prospective coh
239 citations
TL;DR: Randomized trials suggest that patients with acute hypoxemic respiratory failure are less likely to require endotracheal intubation when NPPV is added to standard therapy, however, the effect on mortality is less clear.
Abstract: Context: The results of studies on noninvasive positive pressure ventilation (NPPV) for acute hypoxemic respiratory failure unrelated to cardiogenic pulmonary edema have been inconsistent. Objective: To assess the effect of NPPV on the rate of endotracheal intubation, intensive care unit and hospital length of stay, and mortality for patients with acute hypoxemic respiratory failure not due to cardiogenic pulmonary edema. Data Source: We searched the databases of MEDLINE (1980 to October 2003) and EMBASE (1990 to October 2003). Additional data sources included the Cochrane Library, personal files, abstract proceedings, reference lists of selected articles, and expert contact. Study Selection: We included studies if a) the design was a randomized controlled trial; b) patients had acute hypoxemic respiratory failure not due to cardiogenic pulmonary edema; c) the interventions compared noninvasive ventilation and standard therapy with standard therapy alone; and d) outcomes included need for endotracheal intubation, length of intensive care unit or hospital stay, or intensive care unit or hospital survival. Data Extraction: In duplicate and independently, we abstracted data to evaluate methodological quality and results. Data Synthesis: The addition of NPPV to standard care in the setting of acute hypoxemic respiratory failure reduced the rate of endotracheal intubation (absolute risk reduction 23%, 95% confidence interval 10–35%), ICU length of stay (absolute reduction 2 days, 95% confidence interval 1–3 days), and ICU mortality (absolute risk reduction 17%, 95% confidence interval 8–26%). However, trial results were significantly heterogeneous. Conclusion: Randomized trials suggest that patients with acute hypoxemic respiratory failure are less likely to require endotracheal intubation when NPPV is added to standard therapy. However, the effect on mortality is less clear, and the heterogeneity found among studies suggests that effectiveness varies among different populations. As a result, the literature does not support the routine use of NPPV in all patients with acute hypoxemic respiratory failure.
236 citations
TL;DR: Important developments in evidence based medicine over the subsequent decade included the increasing popularity of structured abstracts and secondary journals summarising evidence from clinical research and the application of formal rules of evidence in evaluating the clinical literature.
Abstract: The second decade will be as exciting as the first
Evidence based medicine seeks to empower clinicians so that they can develop independent views regarding medical claims and controversies. Although many helped to lay the foundations of evidence based medicine,1 Archie Cochrane's insistence that clinical disciplines summarise evidence concerning their practices, Alvan Feinstein's role in defining the principles of quantitative clinical reasoning, and David Sackett's innovation in teaching critical appraisal all proved seminal. The term evidence based medicine,2 and the first comprehensive description of its tenets, appeared little more than a decade ago. In its original formulation, this discipline reduced the emphasis on unsystematic clinical experience and pathophysiological rationale, and promoted the examination of evidence from clinical research. Evidence based medicine therefore required new skills including efficient literature searching and the application of formal rules of evidence in evaluating the clinical literature.
Important developments in evidence based medicine over the subsequent decade included the increasing popularity of structured abstracts3 and secondary journals summarising …
233 citations
TL;DR: No significant differences exist between survivors and nonsurvivors with respect to baseline PC levels, F1 + 2 levels, and APACHE II (acute physiology and chronic health evaluation) scores, and baseline APC levels were higher in survivors and baseline F1 - 2/APC ratios were lower in survivors, suggesting that APC generation is impaired in the latter.
156 citations
TL;DR: It was found that LMWH did not significantly affect the number of bleeding events and seemed to be as safe as UFH in terms of bleeding complications and as effective in preventing extracorporeal circuit thrombosis.
Abstract: Low molecular weight heparins (LWMH) are the preferred initial treatment for many thromboembolic disorders but are renally excreted and relatively contraindicated in patients with renal failure because of concerns of increased bleeding risks. The purpose of this study was to evaluate the safety and efficacy of LMWH compared with unfractionated heparin (UFH) for preventing thrombosis of the extracorporeal dialysis circuit. Studies were identified with the use of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and FirstSearch; reference lists were reviewed; and pharmaceutical companies were contacted. Randomized, controlled trials that compared an LMWH with another anticoagulant during hemodialysis in patients with ESRD and reported at least one of bleeding, extracorporeal circuit thrombosis, or anti-Xa levels were chosen. Two reviewers independently extracted data on methodologic quality, study design, clinical outcomes, and anti-Xa levels. Seventeen trials were included in this systematic review, 11 of which were included in the meta-analysis. It was found that LMWH did not significantly affect the number of bleeding events (relative risk, 0.96; 95% confidence interval [CI], 0.27 to 3.43), bleeding assessed by vascular access compression time (weighted mean difference, -0.87; 95% CI, -2.75 to 1.02), or extracorporeal circuit thrombosis (relative risk, 1.15; 95% CI, 0.70 to 1.91) as compared with UFH. LMWH seem to be as safe as UFH in terms of bleeding complications and as effective as UFH in preventing extracorporeal circuit thrombosis. However, inferences from these trials assessing anticoagulation for patients who undergo hemodialysis will continue to be weak until larger, more rigorous randomized trials are conducted.
152 citations
TL;DR: In this article, grades of recommendation for antithrombotic and thrombolytic therapy are given by considering the trade-off between the benefits of a treatment and the risks, burdens, and costs.
119 citations
TL;DR: Evidence strongly supports a policy of not-for-profit health care delivery at the hospital level after a systematic review and meta-analysis of observational studies that directly compared the payments for care at private for-profit and private not-For-profit hospitals.
Abstract: Background: It has been shown that patients cared for at private for-profit hospitals have higher risk-adjusted mortality rates than those cared for at private not-for-profit hospitals. Uncertainty remains, however, about the economic implications of these forms of health care delivery. Since some policy-makers might still consider for-profit health care if expenditure savings were sufficiently large, we undertook a systematic review and meta-analysis to compare payments for care at private forprofit and private not-for-profit hospitals. Methods: We used 6 search strategies to identify published and unpublished observational studies that directly compared the payments for care at private for-profit and private not-forprofit hospitals. We masked the study results before teams of 2 reviewers independently evaluated the eligibility of all studies. We confirmed data or obtained additional data from all but 1 author. For each study, we calculated the payments for care at private for-profit hospitals relative to private notfor-profit hospitals and pooled the results using a random effects model. Results: Eight observational studies, involving more than 350 000 patients altogether and a median of 324 hospitals each, fulfilled our eligibility criteria. In 5 of 6 studies showing higher payments for care at private for-profit hospitals, the difference was statistically significant; in 1 of 2 studies showing higher payments for care at private not-for-profit hospitals, the difference was statistically significant. The pooled estimate demonstrated that private for-profit hospitals were associated with higher payments for care (relative payments for care 1.19, 95% confidence interval 1.07–1.33, p = 0.001). Interpretation: Private for-profit hospitals result in higher payments for care than private not-for-profit hospitals. Evidence strongly supports a policy of not-for-profit health care delivery at the hospital level.
TL;DR: This work outlines an approach to the measurement and utilization of family satisfaction data so that these data can be translated into health care quality improvement initiatives.
Abstract: Background:Improvement of clinical care requires measurement of key dimensions of health care quality and action based on these measurements. Families, data analysts, clinicians, and administrators all have important roles to play.Objective:To outline an approach to the measurement and utilization o
TL;DR: A series of principles that govern the ethical conduct of clinical research involving critically ill patients are presented and specific recommendations based on these principles are made, including the use of ethical checklists as tools to assist in clinical trial design, implementation, and monitoring.
Abstract: Clinical research involving critically ill patients is necessary to reduce the extreme morbidity and mortality encountered in the intensive care unit (ICU). Yet such research is ethically challenging because critically ill patients usually are unable to consent for research participation, because conflicts of interest occur among investigators, and because discovering new knowledge while simultaneously protecting research participants from risk may be difficult to achieve. To explore these and other challenges and to elucidate ways of meeting them, the American Thoracic Society (ATS) sponsored a conference on the ethical conduct of clinical research involving critically ill patients on November 21 and 22, 2003 in Washington, DC. The conference was initiated in response to a request for proposals from the Association of American Medical Colleges (AAMC), which hoped professional societies would educate their members about the ethical challenges of clinical research. After the AAMC decided to support the conference, further funding was obtained from the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH), and the ATS. At the conference, experts in clinical investigation, patient advocacy, ethics, and research oversight explored various aspects of clinical research with a general audience and a writing committee. The writing committee in turn authored this document. The purpose of the document is to present a series of principles that govern the ethical conduct of clinical research involving critically ill patients and to make specific recommendations based on these principles. Prominent among the recommendations is the use of ethical checklists as tools to assist in clinical trial design, implementation, and monitoring by investigators and independent reviewers of research. Although these recommenda-
TL;DR: Five steps that can improve patients' safety by changing clinician behaviour are described, and they are to do an environmental scan; understand current behaviour, target behaviour for change, adopt effective strategies to change behaviour, and synergise.
TL;DR: There are few implementation strategies that are of unequivocal, consistent benefit, and that are clearly and consistently worth resource investment, and fully informed decisions will require additional research to identify effective guideline implementation strategies.
TL;DR: Wide variation in the management of acute respiratory distress syndrome appears related to limited awareness of relevant research, conflicting interpretations of research findings, and adherence to varying local practice patterns.
Abstract: ObjectiveTo determine physicians’ opinions and practices related to the management of patients with acute respiratory distress syndrome.DesignCross-sectional mail survey.SettingProvince of Ontario, Canada.ParticipantsPhysicians treating patients with acute respiratory distress syndrome at university
TL;DR: Attention to beliefs and attitudes of ICU clinicians about glycemic control could enhance the success of future clinical, educational and research efforts to modify clinician behavior and achieve better gly glucose control in the ICU setting.
Abstract: Intensive insulin therapy has recently been shown to decrease morbidity and mortality in the critically ill population in a large randomized clinical trial. To determine the beliefs and attitudes of ICU clinicians about glycemic control. Self-administered survey. ICU nurses and physicians in five university-affiliated multidisciplinary ICUs. A total of 317 questionnaires were returned from 233 ICU nurses and 84 physicians. The reported clinically important threshold for hypoglycemia was 4 mmol/l (median, IQR 3–4 mmol/l). In non-diabetic patients, the clinically important threshold for hyperglycemia was 10 mmol/l (IQR 9–12 mmol/l); however, nurses had a significantly higher threshold than physicians (difference of 0.52 mmol/l (95% CI 0.09–0.94 mmol/l, P=0.018). In diabetic patients, the clinically important threshold for hyperglycemia was also 10 mmol/l (IQR 10–12 mmol/l), and again nurses had a significantly higher threshold than physicians (0.81 mmol/l, 95% CI 0.29–1.32 mmol/l, P=0.0023). Avoidance of hyperglycemia was judged most important for diabetic patients (87.7%, 95% CI 84.1–91.3%), patients with acute brain injury (84.5%, 95% CI 80.5–88.5%), patients with a recent seizure (74.4%, 95% CI 69.6–79.3%), patients with advanced liver disease (64.0%, 95% CI 58.7–69.3%), and for patients with acute myocardial infarction (64.0%, 95% CI 58.7–69.3%). Physicians expressed more concern than nurses about avoiding hyperglycemia in patients with acute myocardial infarction (P=0.0004). ICU clinicians raised concerns about the accuracy of glucometer measurements in critically ill patients (46.1%, 95% CI 40.5–51.6%). Attention to these beliefs and attitudes could enhance the success of future clinical, educational and research efforts to modify clinician behavior and achieve better glycemic control in the ICU setting.
TL;DR: Advance directive completion rates documenting patient preferences for end-of-life care may be increased by simple patient-directed educational interventions.
TL;DR: Most patients were perceived by family members to die in comfort during a withdrawal of LS, and perceptions of patient comfort and drug use in the hours before death were not associated with the mode or sequence of withdrawal ofLS, or the time to death.
Abstract: Purpose: Most deaths in intensive care units (ICUs) follow a withdrawal of life support (LS). Evaluation of this process including the related perspectives of grieving family members is integral to improvement of palliation in the ICU. Methods: A prospective, multicentre, cohort study in six Canadian university-affiliated ICUs included 206 ICU patients (length of stay $ 48 hr) who received mechanical ventilation (MV) before LS withdrawal. We recorded modes, sequence and time course of LS withdrawal and drug usage (4 hr before; 4–8 hr and 8–12 hr before death). We asked a specified family member to assess patient comfort and key aspects of end-of life care. Results: MV was withdrawn from 155/206 (75.2%) patients; 97/155 (62.6%) died after extubation and 58/155 (37.4%) died with an airway in place. The most frequently used drugs and the cumulative doses [median (range)] in the four hours before death were: morphine 119/206, 24 mg, (2–450 mg); midazolam 45/206, 24 mg, (2–380 mg); and lorazepam 35/206, 4 mg, (1–80 mg). These doses did not differ among the three time periods before death. Of 196 responses from family members most indicated that patients were perceived to be either totally (73, 37.2%), very (48, 24.5%), or mostly comfortable (58, 29.6%). Times to death, morphine use and family members’ perceptions of comfort were similar for each type of change to MV. Conclusions: Most patients were perceived by family members to die in comfort during a withdrawal of LS. Perceptions of patient comfort and drug use in the hours before death were not associated with the mode or sequence of withdrawal of LS, or the time to death.
TL;DR: Adoption of some of these strategies described may lead to improved end-of-life care in the ICU, and future studies should include more formal evaluation of the efficacy of end- of-life interventions to help ensure high quality, clinically relevant, culturally adapted care for all dying critically ill patients.
Abstract: Purpose
Since 10 to 20% of adult patients admitted to the intensive care unit (ICU) in Canada die, addressing the needs of dying critically ill patients is of paramount importance. The purpose ofthis article is to suggest some strategies to consider to improve the care of patients dying in the ICU.
TL;DR: One third of mechanically ventilated patients had DNR directives established early during their ICU stay after the first 24 hr of admission, and the strongest predictors were physician prediction of low probability of survival, physician perception of patient preference to limit life support, organ dysfunction, medical diagnosis and age.
Abstract: Purpose: Setting treatment goals in the intensive care unit (ICU) often involves resuscitation decisions. Our objective was to study the rate of establishing do-not-resuscitate (DNR) directives, determinants, and outcomes of those directives for mechanically ventilated patients. Methods: In a multicentre observational study, we included consecutive adults with no DNR directives within 24 hr of ICU admission who were mechanically ventilated for at least 48 hr. We identified the rate with which DNR directives were established, and factors associated with these directives. Results: Among 765 patients, DNR directives were established for 231 (30.2%) patients; 143 (62.1%) of these were established within the first week. Factors independently associated with a DNR directive were: patient age [$ 75 yr (hazard ratio [HR] 2.3, 95% confidence interval 1.5–3.4], 65 to 74 yr (HR 1.8, 1.2–2.7), 50 to 64 yr (HR 1.4, 1.0–2.2) relative to 90%]; and physician perception of patient preference to limit life support (no
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TL;DR: In a study of fluid resuscitation involving nearly 7000 critically ill patients, the Australian and New Zealand Intensive Care Society Clinical Trials Group addressed one of the most fundamental and contentious issues in critical care.
Abstract: The Saline versus Albumin Fluid Evaluation (SAFE) Study, reported in this issue of the Journal, 1 heralds a new era in critical care marked by the large, simple, randomized trial popularized by cardiologists. In a study of fluid resuscitation involving nearly 7000 critically ill patients, the Australian and New Zealand Intensive Care Society Clinical Trials Group addressed one of the most fundamental and contentious issues in critical care. Questions about the merits and demerits of colloids as opposed to crystalloids in the resuscitation of seriously ill patients have smoldered for decades, sparked by a meta-analysis suggesting that albumin was associated with . . .
TL;DR: The Seventh American College of Chest Physicians (ACCP) Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines as mentioned in this paper is the most widely used evidence-based guideline.
TL;DR: Clinician discomfort with life support perceived as too technologically intense is common, experienced mostly by nurses, variable across centers, and is more likely for older, severely ill medical patients, those with acute renal failure, and patients lacking plans to forgo reintubation and ventilation.
Abstract: To examine the incidence and predictors of clinician discomfort with life support plans for ICU patients. Prospective cohort in 13 medical-surgical ICUs in four countries. 657 mechanically ventilated adults expected to stay in ICU at least 72 h. Daily we documented the life support plan for mechanical ventilation, inotropes and dialysis, and clinician comfort with these plans. If uncomfortable, clinicians stated whether the plan was too technologically intense (the provision of too many life support modalities or the provision of any modality for too long) or not intense enough, and why. At least one clinician was uncomfortable at least once for 283 (43.1%) patients, primarily because plans were too technologically intense rather than not intense enough (93.9% vs. 6.1%). Predictors of discomfort because plans were too intense were: patient age, medical admission, APACHE II score, poor prior functional status, organ dysfunction, dialysis in ICU, plan to withhold dialysis, plan to withhold mechanical ventilation, first week in the ICU, clinician, and city. Clinician discomfort with life support perceived as too technologically intense is common, experienced mostly by nurses, variable across centers, and is more likely for older, severely ill medical patients, those with acute renal failure, and patients lacking plans to forgo reintubation and ventilation. Acknowledging the sources of discomfort could improve communication and decision making
TL;DR: The objective of the present survey is to identify the patient factors and radiologic features of lower limb DVT that intensivists consider more or less likely to make a DVT clinically important in ICU patients.
Abstract: Outside the intensive care unit (ICU), clinically important deep vein thrombosis (DVT) is usually defined as a symptomatic event that leads to objective radiologic confirmation and subsequent treatment. The objective of the present survey is to identify the patient factors and radiologic features of lower limb DVT that intensivists consider more or less likely to make a DVT clinically important in ICU patients. Our definition of clinically important DVT was a DVT likely to result in short-term or long-term morbidity or mortality if left untreated, as opposed to a DVT that is unlikely to have important consequences. We asked respondents to indicate the likelihood that patient factors and ultrasonographic features make a DVT clinically important using a five-point scale (from 1 = much less likely to 5 = much more likely). Of the 71 Canadian intensivists who responded, 70 (99%) rated three patient factors as most likely to make a DVT clinically important: clinical suspicion of pulmonary embolism (mean score 4.6), acute or chronic cardiopulmonary morbidity that might limit a patient's ability to tolerate pulmonary embolism (score 4.5), and leg symptoms (score 4.2). Of the ultrasound features, proximal (score 4.7), large (score 4.2), and totally occlusive (score 3.9) thrombi were considered the three most important. When labeling a DVT as clinically important, intensivists rely on different patient specific factors and thrombus characteristics than are used to assess the clinical importance of DVT outside the ICU. The clinical importance of DVT is influenced by unique factors such as cardiopulmonary reserve among mechanically ventilated patients.
01 Jan 2004
TL;DR: A scenario-based, cross-sectional survey of Canadian critical care medicine and infectious disease specialists about the use of intravenous immunoglobulin for the treatment of severe infections found specialist's beliefs surrounding the efficacy of IVIG would challenge but not preclude the conduct of future placebo controlled trials of severe streptococcal infections.
TL;DR: LMWHs appear to be as safe as UFH in terms of bleeding complications, and as effective in preventing extracorporeal circuit thrombosis, however, inferences from these trials assessing anticoagulation for patients undergoing hemodialysis will continue to be weak until larger, more rigorous randomized trials are conducted.
TL;DR: DVT rates remain high in medical-surgical ICU patients despite universal heparin thromboprophylaxis, and this pilot study suggests that a randomized clinical trial comparing LMWH vs UFH feasible.