Showing papers by "Deborah J. Cook published in 2006"

An Official ATS Statement: Grading the Quality of Evidence and Strength of Recommendations in ATS Guidelines and Recommendations

Abstract: Grading the strength of recommendations and the quality of underlying evidence enhances the usefulness of clinical practice guidelines. Professional societies and other organizations, including the American Thoracic Society (ATS), should reach consensus about whether they will use one common grading system and which of the numerous grading systems they would apply across all guidelines. The profusion of guideline grading systems confuses consumers of guidelines, and undermines the value of the grading exercise in conveying a transparent message. In response to this dilemma, the international GRADE working group has developed an approach that is useful for many guideline contexts, and that several national and international organizations have adopted. The GRADE system classifies recommendations as strong or weak, according to the balance of the benefits and downsides (harms, burden, and cost) after considering the quality of evidence. The quality of evidence reflects the confidence in estimates of the true effects of an intervention, and the system classifies quality of evidence as high, moderate, low, or very low according to factors that include the study methodology, the consistency and precision of the results, and the directness of the evidence. On recommendation of the ATS Documents Development and Implementation Committee, the ATS adopted the GRADE approach for its guidelines in line with many other organizations that have recently chosen the GRADE approach. This article informs ATS guideline developers, investigators, and those interpreting future ATS guidelines that follow the GRADE approach about the methodology and applicability of ATS guidelines and recommendations.

Two-year outcomes, health care use, and costs of survivors of acute respiratory distress syndrome.

Abstract: Rationale: Little is known about the long-term outcomes and costs of survivors of acute respiratory distress syndrome (ARDS).Objectives: To describe functional and quality of life outcomes, health care use, and costs of survivors of ARDS 2 yr after intensive care unit (ICU) discharge.Methods: We recruited a cohort of ARDS survivors from four academic tertiary care ICUs in Toronto, Canada, and prospectively monitored them from ICU admission to 2 yr after ICU discharge.Measurements: Clinical and functional outcomes, health care use, and direct medical costs.Results: Eighty-five percent of patients with ARDS discharged from the ICU survived to 2 yr; overall 2-yr mortality was 49%. At 2 yr, survivors continued to have exercise limitation although 65% had returned to work. There was no statistically significant improvement in health-related quality of life as measured by Short-Form General Health Survey between 1 and 2 yr, although there was a trend toward better physical role at 2 yr (p = 0.0586). Apart from ...

Intensive care unit quality improvement: a "how-to" guide for the interdisciplinary team.

Abstract: Objective: Quality improvement is an important activity for all members of the interdisciplinary critical care team. Although an increasing number of resources are available to guide clinicians, quality improvement activities can be overwhelming. Therefore, the Society of Critical Care Medicine charged this Outcomes Task Force with creating a “how-to” guide that focuses on critical care, summarizes key concepts, and outlines a practical approach to the development, implementation, evaluation, and maintenance of an interdisciplinary quality improvement program in the intensive care unit. Data Sources and Methods: The task force met in person twice and by conference call twice to write this document. We also conducted a literature search on “quality improvement” and “critical care or intensive care” and searched online for additional resources. Data Synthesis and Overview: We present an overview of quality improvement in the intensive care unit setting and then describe the following steps for initiating or improving an interdisciplinary critical care quality improvement program: a) identify local motivation, support teamwork, and develop strong leadership; b) prioritize potential projects and choose the first target; c) operationalize the measures, build support for the project, and develop a business plan; d) perform an environmental scan to better understand the problem, potential barriers, opportunities, and resources for the project; e) create a data collection system that accurately measures baseline performance and future improvements; f) create a data reporting system that allows clinicians and others to understand the problem; g) introduce effective strategies to change clinician behavior. In addition, we identify four steps for evaluating and maintaining this program: a) determine whether the target is changing with periodic data collection; b) modify behavior change strategies to improve or sustain improvements; c) focus on interdisciplinary collaboration; and d) develop and sustain support from the hospital leadership. We also identify a number of online resources to complement this overview. Conclusions: This Society of Critical Care Medicine Task Force report provides an overview for clinicians interested in developing or improving a quality improvement program using a step-wise approach. Success depends not only on committed interdisciplinary work that is incremental and continuous but also on strong leadership. Further research is needed to refine the methods and identify the most cost-effective means of improving the quality of health care received by critically ill patients and their families. (Crit Care Med 2006; 34:211–218)

Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients

Abstract: Objectives:To characterize the perceived utilization of sedative, analgesic, and neuromuscular blocking agents, the use of sedation scales, algorithms, and daily sedative interruption in mechanically ventilated adults, and to define clinical factors that influence these practices.Design:Cross-sectio

Mortality predictions in the intensive care unit: comparing physicians with scoring systems.

Abstract: Objective:Risk-prediction models offer potential advantages over physician predictions of outcomes in the intensive care unit (ICU). Our systematic review compared the accuracy of ICU physicians' and scoring system predictions of ICU or hospital mortality of critically ill adults.Data Source:MEDLINE

End-of-life care for the critically ill: A national intensive care unit survey.

Abstract: Objective:One in five Americans dies following treatment in an intensive care unit (ICU), and evidence indicates the need to improve end-of-life care for ICU patients. We conducted this study to elicit the views and experiences of ICU directors regarding barriers to optimal end-of-life care and to i

Rationing in the intensive care unit.

Abstract: Background:Critical care services represent a large and growing proportion of health care expenditures. Limiting the magnitude of these costs while maintaining a just allocation of these services will require rationing. We define rationing as “the allocation of healthcare resources in the face of li

Elevated Cardiac Troponin Measurements in Critically Ill Patients

Abstract: Background: The clinical significance of elevated cardiac troponin (cTn) level in patients in the intensive care unit (ICU) is uncertain. We reviewed the frequency of cTn elevation and its association with mortality and length of ICU stay in these patients. Methods: Studies were identified using MEDLINE, EMBASE, and reference list review. We included observational studies of critically ill patients that measured cTn at least once and reported the frequency of elevated cTn or outcome (mortality and length of ICU or hospital stay). We pooled the odds ratios (ORs) using the inverse variance method in studies that conducted multivariable analysis to examine the relationship between elevated cTn and mortality (adjusted analysis). We calculated the weighted mean difference in length of stay between patients with and without elevated cTn and pooled the results using the inverse variance method (unadjusted analysis). Results: A total of 23 studies involving 4492 critically ill patients were included. In 20 studies, elevated cTn was found in a median of 43% (interquartile range, 21% to 59%) of 3278 patients. In adjusted analysis (6 studies comprising 1706 patients), elevated cTn was associated with an increased risk of death (OR, 2.5; 95% confidence interval [CI], 1.9 to 3.4;P.001). In the unadjusted analysis (8 studies comprising 1019 patients), elevated cTn was associated with an increased length of ICU stay of 3.0 days (95% CI, 1.0 to 5.1 days;P=.004) and an increased length of hospital stay of 2.2 days (95% CI, �0.6 to 4.9; P=.12). Conclusions: Elevated cTn measurements among critically ill patients are associated with increased mortality and ICU length of stay. Research is needed to clarify the underlying causes of elevated cTn in this population and to examine their clinical significance. Arch Intern Med. 2006;166:2446-2454

REducing Deaths due to OXidative Stress (The REDOXS© Study): rationale and study design for a randomized trial of glutamine and antioxidant supplementation in critically-ill patients

Abstract: Critically-ill patients experience an extent of hyperinflammation, cellular immune dysfunction, oxidative stress and mitochondrial dysfunction. Supplementation with key nutrients, such as glutamine and antioxidants, is most likely to have a favourable effect on these physiological derangements, leading to an improvement in clinical outcomes. The results of two meta-analyses suggest that glutamine and antioxidants may be associated with improved survival. The purpose of the present paper is to report the background rationale and study protocol for the evaluation of the effect of high-dose glutamine and antioxidant supplementation on mortality in a large-scale randomized trial in 1200 mechanically-ventilated, critically-ill patients. Patients admitted to an intensive care unit (ICU) with clinical evidence of severe organ dysfunction will be randomized to one of four treatments in a 2 x 2 factorial design: (1) glutamine; (2) antioxidant therapy; (3) glutamine and antioxidant therapy; (4) placebo. The primary outcome for this study is 28 d mortality. The secondary outcomes are duration of stay in ICU, adjudicated diagnosis of infection, multiple organ dysfunction, duration of mechanical ventilation, length of stay in hospital and health-related quality of life at 3 and 6 months. A novel design feature is the combined use of parenteral and enteral study nutrients dissociated from the nutrition support. The therapeutic strategies tested in the randomized trial may lead to less morbidity and improved survival in critically-ill patients. The trial will be conducted in approximately twenty tertiary-care ICU in Canada and the first results are expected in 2009.

Avoiding transfusions in children undergoing cardiac surgery: a meta-analysis of randomized trials of aprotinin.

Abstract: Aprotinin, a potent antifibrinolytic drug, reduces the proportion of adults who receive blood transfusions during cardiac surgery, although the effect in children remains unclear. We performed a systematic review of the literature to identify all English language, randomized controlled trials of aprotinin involving children undergoing corrective or palliative cardiac surgery with cardiopulmonary bypass. All studies were assessed for methodological quality, and sources of heterogeneity were examined. We measured the effect of aprotinin on the proportion of children transfused, the volume of blood transfused, and the volume of chest tube drainage. Twelve trials enrolling 626 eligible children met the inclusion criteria. Aprotinin reduced the proportion of children who received red blood cell or whole blood transfusions during cardiac surgery by 33% (relative risk = 0.67; 95% confidence interval, 0.51 to 0.89). Aprotinin did not have a significant effect on the volume of blood transfused or on the amount of postoperative chest tube drainage. Most of the studies were of poor methodological quality and predefined transfusion triggers were infrequently used. Overall, aprotinin reduced the proportion of children who received blood transfusion during cardiac surgery with cardiopulmonary bypass. Further high-quality trials with clinically important outcomes may be warranted before aprotinin can be routinely recommended in this population.

Elevated cardiac troponin levels in critically ill patients: prevalence, incidence, and outcomes.

Abstract: • BACKGROUND Levels of cardiac troponin, a sensitive and specific marker of myocardial injury, are often elevated in critically ill patients. • OBJECTIVES To document elevated levels of cardiac troponin I in patients in a medical-surgical intensive care unit and the relationship between elevated levels and electrocardiographic findings and mortality. • METHODS A total of 198 patients expected to remain in the intensive care unit for at least 72 hours were classified as having myocardial infarction (cardiac troponin I level ≥1.2 µg/L and ischemic electrocardiographic changes), elevated troponin level only (≥1.2 µg/L and no ischemic electrocardiographic changes), or normal troponin levels. Events were classified as prevalent if they occurred within 48 hours after admission and as incident if they occurred 48 hours or later after admission. Factors associated with mortality were examined by using regression analysis. • RESULTS A total of 171 patients had at least one troponin level measured in the first 48 hours. The prevalence of elevated troponin level was 42.1% (72 patients); 38 patients (22.2%) had myocardial infarction, and 34 (19.9%) had elevated troponin level only. After the first 48 hours, 136 patients had at least 1 troponin measurement. The incidence of elevated troponin level was 11.8% (16 patients); 7 patients (5.1%) met criteria for myocardial infarction, and 2 (1.5%) had elevated troponin level only. Elevated levels of troponin I at any time during admission were associated with mortality in the univariate but not the multivariate analysis. • CONCLUSIONS Elevated levels of cardiac troponin I in critically ill patients do not always indicate myocardial infarction or an adverse prognosis. (American Journal of Critical Care. 2006;15:280-289)

Minimizing errors of omission: behavioural reenforcement of heparin to avert venous emboli: the BEHAVE study.

Abstract: Objective:To improve patient safety by increasing heparin thromboprophylaxis for medical-surgical intensive care unit patients using a multiple-method approach to evidence-based guideline development and implementation.Design:Prospective longitudinal observational study.Setting:Medical-surgical inte

In-house, overnight physician staffing: a cross-sectional survey of Canadian adult and pediatric intensive care units.

Abstract: Objective Physician staffing is an important determinant of patient outcomes following intensive care unit (ICU) admission. We conducted a national survey of in-house after-hours physician staffing in Canadian ICUs. Design : Cross-sectional survey. Setting Canadian adult and pediatric ICUs. Participants ICU directors. Interventions ICU directors of Canadian adult and pediatric ICUs were surveyed to describe overnight staffing by interns, residents, critical care medicine trainees, clinical assistants, and ICU physicians in their ICUs. Measurements and main results Data were collected regarding hospital and ICU demographics and ICU staffing. For ICUs with in-house overnight physicians, we documented physician experience, shift duration, and clinical responsibilities outside the ICU. We identified 98 Canadian ICU directors, of whom 88 (90%) responded. Dedicated in-house physician coverage overnight was reported in 53 (60%) ICUs, including 13 (15%) in which ICU staff physicians stayed in-house overnight. Compared with ICUs without in-house physicians, those with in-house physicians had more ICU beds (15 vs. 8.5, p=.0001) and fewer ICU staff physicians (5 vs. 7, p=.03). For the 271 physicians who provide overnight staffing, the median level of postgraduate experience was 3 yrs (range, 10 yrs); 129 (48%) had 20 hrs long. Conclusions In-house overnight physician staffing in Canadian ICUs varies widely. Only a minority of ICUs comply with the 2003 Society of Critical Care Medicine guidelines for adult ICUs recommending continuous in-house staffing by ICU staff physicians. The duration of most ICU shifts raises concern about workload-associated fatigue and medical error. The impact of current nighttime staffing requires further evaluation with respect to patient outcomes.

Understanding and changing attitudes toward withdrawal and withholding of life support in the intensive care unit

Abstract: A careful examination of our attitudes toward end-of-life care is critical to our understanding of where change is needed to improve patient outcomes. The objectives of our narrative review are 1) to review why the intensive care unit setting presents particular challenges for the delivery of optimal end-of-life care, 2) to outline how four different research methods can provide insights into our understanding of attitudes about withdrawal of life support, and 3) to suggest seven different approaches to changing prevailing attitudes toward withdrawal of life support in the intensive care unit. To better understand attitudes about end-of-life care in general and withdrawal of life support in particular, we reviewed four different sources of data: 1) decision support tools, 2) qualitative research, 3) surveys, and 4) observational studies. Understanding these attitudes offers valuable insights about strategies that may help to improve the care of dying patients and their families. There are several ways to change attitudes; the approaches we reviewed are 1) promoting social change professionally, 2) legitimizing end-of-life research, 3) determining what families of dying patients need, 4) initiating quality improvement locally, 5) evaluating the benefits and harms of new initiatives, 6) modeling quality end-of-life care for future clinicians, and 7) using narratives. Attitudes toward end-of-life care are influenced by many factors and change slowly. Our attitudes have social and personal origins; they are grounded in values that are collective and community based. Different research methods provide insights into attitudes toward death in the intensive care unit and withdrawal of life support in particular. Understanding these attitudes may offer valuable insights about strategies that should help improve the care for dying patients and their families.

Decision tools for life support: A review and policy analysis

Abstract: Objective:To identify, describe, and compare published documents intended to guide decisions about the administration, withholding, or withdrawal of life support in critical care.Design:Review article.Setting and Sources:Publicly available, English-language guidelines or decision tools for life supp

Brief review: Practice variation in end of life care in the ICU: implications for patients with severe brain injury

Abstract: To review end of life care issues in the intensive care unit (ICU) and how practice variation might affect the ultimate outcome of acute brain injury. Bibliographic literature search and personal files. In Canada, 10-20% of critically ill adults die in the ICU. Many of these deaths follow acute brain injury in the setting of clinical deterioration, life support limitation and brain death. This brief review addresses some key elements of end of life care for critically ill brain injured patients, including family interactions, making survival predictions, and factors influencing decision-making about cardiopulmonary resuscitation and withdrawal of mechanical ventilation. Provision of compassionate high quality end of life care should be standard of practice for brain injured and all other critically ill patients who cannot survive. Inconsistencies in end of life care may affect where, when and how patients die, the quality of their death and whether or not they are considered for organ and tissue donation.

Reliability of electrocardiogram interpretation in critically ill patients.

Abstract: Objective To assess the intrarater and interrater reliability of electrocardiogram (ECG) interpretation in critically ill patients and to assess the effect of knowledge of cardiac troponin values on these reliability estimates Design Prospective cohort study Setting Fifteen-bed medical-surgical intensive care unit Patients Consecutive adults admitted over a 2-month period Measurements and results All consecutive 12-lead ECGs were interpreted independently by two raters for the presence of myocardial ischemia or infarction and secondarily for specific ischemic ECG abnormalities The ECGs were first interpreted blinded to the patient's troponin levels and reinterpreted on two separate occasions, blinded and unblinded to the troponin values Results are reported using chance-independent agreement (phi) with associated 95% confidence intervals For the presence of ischemia or infarction, the intrarater reliability ranged from fair to moderate (phi = 035 [95% confidence interval = 016, 052] and 059 [033, 077] for the two raters, respectively); interrater reliability was slight when blinded to troponin levels (phi = 018 [003, 032]) and increased to moderate when the raters were unblinded to troponin values (phi = 052 [033, 066], p value for the difference = 004) For specific ECG changes, the intrarater and interrater reliability were low for T-wave flattening, whereas detection of a left bundle branch block showed high reliability Conclusions ECG interpretation in critically ill patients for the presence of myocardial ischemia or infarction showed moderate reliability at best; however, there was high reliability for specific ECG changes Knowledge of the patient's troponin values increased the reliability for all studied ECG changes and resulted in a statistically significant increase in the interrater reliability for diagnosing myocardial ischemia or infarction Additional studies assessing the appropriate methods of diagnosing myocardial ischemia and infarction and assessing the reliability of these diagnostic tests in critically ill patients are required

Levels of care in the intensive care unit: a research program.

Abstract: A multidisciplinary research program on levels of care was conducted in 15 adult intensive care units in North America, Europe, and Australia. The program addressed advance directives for cardiopulmonary resuscitation, provision of advanced life support, and clinicians’ discomfort with evolving treatment plans. The results indicated that the factors that determined the establishment of directives for advance life support differed from the factors that informed a decision to limit or withdraw support after admission to an intensive care unit. In addition, clinicians’ prognoses were imprecise and often an underestimation of the probability of short-term survival. Finally, some degree of discomfort was common in care providers in the intensive care unit, most often because they thought interventions were excessive and not compatible with an acceptable future quality of life. The provision of advanced life support mandates explicit decision making about how life-support measures should be used. (American Journal of Critical Care. 2006;15:269-279)

The Canadian CT Head Rule was as sensitive as, but more specific than, the New Orleans Criteria for identifying minor head injury.

Abstract: Source Citation Stiell IG, Clement CM, Rowe BH, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA. 2005;294:1511-8. 16189364

Oral decontamination with chlorhexidine reduced ventilator-associated pneumonia in high-risk patients.

Abstract: Source Citation Koeman M, van der Ven AJ, Hak E, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med. 2006;173:1348-55...