Mauricio Ferri

Caring for Critically Ill Patients with Ebola Virus Disease. Perspectives from West Africa

The largest ever Ebola virus disease outbreak is ravaging West Africa. The constellation of little public health infrastructure, low levels of health literacy, limited acute care and infection prevention and control resources, densely populated areas, and a highly transmissible and lethal viral infection have led to thousands of confirmed, probable, or suspected cases thus far. Ebola virus disease is characterized by a febrile severe illness with profound gastrointestinal manifestations and is complicated by intravascular volume depletion, shock, profound electrolyte abnormalities, and organ dysfunction. Despite no proven Ebola virus-specific medical therapies, the potential effect of supportive care is great for a condition with high baseline mortality and one usually occurring in resource-constrained settings. With more personnel, basic monitoring, and supportive treatment, many of the sickest patients with Ebola virus disease do not need to die. Ebola virus disease represents an illness ready for a paradigm shift in care delivery and outcomes, and the profession of critical care medicine can and should be instrumental in helping this happen.

A systematic review of evidence-informed practices for patient care rounds in the ICU*.

Objectives:Patient care rounds are a key mechanism by which healthcare providers communicate and make patient care decisions in the ICU but no synthesis of best practices for rounds currently exists. Therefore, we systematically reviewed the evidence for facilitators and barriers to patient care rounds in the ICU. Data Sources:Search of Medline, Embase, CINAHL, PubMed, and the Cochrane library through September 21, 2012. Study Selection:Original, peer-reviewed research studies (no methodological restrictions) were selected, which described current practices, facilitators, or barriers to healthcare provider rounding in the ICU. Data Extraction:Two authors with methodological and content expertise independently abstracted data using a prespecified abstraction tool. Data Synthesis:The literature search identified 7,373 citations. Reviews of abstracts led to the retrieval of 136 full text articles for assessment; 43 articles in three languages (English, German, Spanish) were selected for review. Of these, 13 were ethnographic studies and 15 uncontrolled before-after studies. Six studies used control groups, including one cross-over randomized, one time-series, three cohort, and one controlled before-after study. A total of 13 facilitators and 9 barriers to patient care rounds were identified through a narrative and meta-synthesis of included studies. Identified facilitators suggest that the quality of rounds is improved when conducted by a multidisciplinary group of providers, with explicitly defined roles, using a standardized structure and goal-oriented approach that includes a best practices checklist. Barriers to quality patient care rounds include poor information retrieval and documentation, interruptions, long rounding times, and allied healthcare provider perceptions of not being valued by rounding physicians. Conclusions:Although the evidence base for best practices of patient care rounds in the ICU is limited, several practical and low-risk practices can be considered for implementation. (Crit Care Med 2013; 41:2015–2029)

Being ready to treat Ebola virus disease patients.

As the outbreak of Ebola virus disease (EVD) in West Africa continues, clinical preparedness is needed in countries at risk for EVD (e.g., United States) and more fully equipped and supported clinical teams in those countries with epidemic spread of EVD in Africa. Clinical staff must approach the patient with a very deliberate focus on providing effective care while assuring personal safety. To do this, both individual health care providers and health systems must improve EVD care. Although formal guidance toward these goals exists from the World Health Organization, Medecin Sans Frontières, the Centers for Disease Control and Prevention, and other groups, some of the most critical lessons come from personal experience. In this narrative, clinicians deployed by the World Health Organization into a wide range of clinical settings in West Africa distill key, practical considerations for working safely and effectively with patients with EVD.

Effectiveness of Personal Protective Equipment for Healthcare Workers Caring for Patients with Filovirus Disease: A Rapid Review.

Background A rapid review, guided by a protocol, was conducted to inform development of the World Health Organization’s guideline on personal protective equipment in the context of the ongoing (2013–present) Western African filovirus disease outbreak, with a focus on health care workers directly caring for patients with Ebola or Marburg virus diseases. Methods Electronic databases and grey literature sources were searched. Eligibility criteria initially included comparative studies on Ebola and Marburg virus diseases reported in English or French, but criteria were expanded to studies on other viral hemorrhagic fevers and non-comparative designs due to the paucity of studies. After title and abstract screening (two people to exclude), full-text reports of potentially relevant articles were assessed in duplicate. Fifty-seven percent of extraction information was verified. The Grading of Recommendations Assessment, Development and Evaluation framework was used to inform the quality of evidence assessments. Results Thirty non-comparative studies (8 related to Ebola virus disease) were located, and 27 provided data on viral transmission. Reporting of personal protective equipment components and infection prevention and control protocols was generally poor. Conclusions Insufficient evidence exists to draw conclusions regarding the comparative effectiveness of various types of personal protective equipment. Additional research is urgently needed to determine optimal PPE for health care workers caring for patients with filovirus.

Evidence-based design in an intensive care unit: End-user perceptions

BackgroundThe objective of this study was to describe end-user impressions and experiences in a new intensive care unit built using evidence-based design.MethodsThis qualitative study was comprised of early (2–3 months after opening) and late (12–15 months after opening) phase individual interviews with end-users (healthcare providers, support staff, and patient family members) of the newly constructed Foothills Medical Centre intensive care unit in Calgary, Canada. The study unit was the recipient of the Society of Critical Care Medicine Design Citation award in 2012.ResultsWe conducted interviews with thirty-nine ICU end-users, twenty-four in the early phase and fifteen in the late phase. We identified four themes (eleven sub-themes): atmosphere (abundant natural light and low noise levels), physical spaces (single occupancy rooms, rooms clustered into clinical pods, medication rooms, and tradeoffs of larger spaces), family participation in care (family support areas and social networks), and equipment (usability, storage, and providers connectivity). Abundant natural light was the design feature most frequently associated with a pleasant atmosphere. Participants emphasized the tradeoffs of size and space, and reported that the benefits of additional space (e.g., fewer interruptions due to less noise) out-weighed the disadvantages (e.g., greater distances between patients, families and providers). End-users advised that local patient care policies (e.g., number of visitors allowed at a time) and staffing needed to be updated to reflect the characteristics of the new facility design.ConclusionsEnd-users identified design elements for creating a pleasant atmosphere, attention to the tradeoffs of space and size, designing family support areas to encourage family participation in care, and updating patient care policies and staffing to reflect the new physical space as important aspects to consider when building intensive care units. Evidence-based design may optimize ICU structure for patients, patient families and providers.

Methods for Developing Evidence Reviews in Short Periods of Time: A Scoping Review.

Introduction Rapid reviews (RR), using abbreviated systematic review (SR) methods, are becoming more popular among decision-makers. This World Health Organization commissioned study sought to summarize RR methods, identify differences, and highlight potential biases between RR and SR. Methods Review of RR methods (Key Question 1 [KQ1]), meta-epidemiologic studies comparing reliability/ validity of RR and SR methods (KQ2), and their potential associated biases (KQ3). We searched Medline, EMBASE, Cochrane Library, grey literature, and checked reference lists, used personal contacts, and crowdsourcing (e.g. email listservs). Selection and data extraction was conducted by one reviewer (KQ1) or two reviewers independently (KQ2-3). Results Across all KQs, we identified 42,743 citations through the literature searches. KQ1: RR methods from 29 organizations were reviewed. There was no consensus on which aspects of the SR process to abbreviate. KQ2: Studies comparing the conclusions of RR and SR (n = 9) found them to be generally similar. Where major differences were identified, it was attributed to the inclusion of evidence from different sources (e.g. searching different databases or including different study designs). KQ3: Potential biases introduced into the review process were well-identified although not necessarily supported by empirical evidence, and focused mainly on selective outcome reporting and publication biases. Conclusion RR approaches are context and organization specific. Existing comparative evidence has found similar conclusions derived from RR and SR, but there is a lack of evidence comparing the potential of bias in both evidence synthesis approaches. Further research and decision aids are needed to help decision makers and reviewers balance the benefits of providing timely evidence with the potential for biased findings.

Capture-mark-recapture as a tool for estimating the number of articles available for systematic reviews in critical care medicine☆

INTRODUCTION Systematic reviews are an important knowledge synthesis tool for critical care medicine clinicians and researchers. With new literature available each day, reviewers must balance identifying all relevant literature against timely synthesis. We therefore sought to apply capture-mark-recapture, a novel methodology, to estimate the population of articles available for a systematic review of effective patient rounding practices in critical care medicine. METHODS Capture-mark-recapture was applied retrospectively to estimate the population of articles available for a systematic review of 4 bibliographic databases. All research studies (no methodology restrictions) of patient rounding practices in critical care medicine were included. Estimates of article population size were calculated for search of the bibliographic databases, selection of articles for full-text review, and selection of articles for inclusion in the systematic review. RESULTS Capture-mark-recapture estimated a population of 28839 articles (95% confidence interval [CI], 12393-70990) for search of the bibliographic databases, 169 articles (95% CI, 152-202) for full-text review, and 48 articles (95% CI, 39-131) for inclusion in the systematic review. These estimates suggest that our search identified 15% (4462/28839) of the population of potentially available articles for the search of the bibliographic databases, 79% (133/169) of articles for full-text review, and 79% (38/48) of articles for inclusion in the systematic review. CONCLUSIONS The capture-mark-recapture technique can be applied to systematic reviews in critical care medicine with heterogeneous study methodologies to estimate the population of articles available. Capture-mark-recapture may help clinicians who use systematic reviews to estimate search completeness and researchers who perform systematic reviews to develop more efficient literature search strategies.

Quality improvement practices used by teaching versus non-teaching trauma centres: analysis of a multinational survey of adult trauma centres in the United States, Canada, Australia, and New Zealand

BackgroundAlthough studies have suggested that a relationship exists between hospital teaching status and quality improvement activities, it is unknown whether this relationship exists for trauma centres.MethodsWe surveyed 249 adult trauma centres in the United States, Canada, Australia, and New Zealand (76% response rate) regarding their quality improvement programs. Trauma centres were stratified into two groups (teaching [academic-based or –affiliated] versus non-teaching) and their quality improvement programs were compared.ResultsAll participating trauma centres reported using a trauma registry and measuring quality of care. Teaching centres were more likely than non-teaching centres to use indicators whose content evaluated treatment (18% vs. 14%, p < 0.001) as well as the Institute of Medicine aim of timeliness of care (23% vs. 20%, p < 0.001). Non-teaching centres were more likely to use indicators whose content evaluated triage and patient flow (15% vs. 18%, p < 0.001) as well as the Institute of Medicine aim of efficiency of care (25% vs. 30%, p < 0.001). While over 80% of teaching centres used time to laparotomy, pulmonary complications, in hospital mortality, and appropriate admission physician/service as quality indicators, only two of these (in hospital mortality and appropriate admission physician/service) were used by over half of non-teaching trauma centres. The majority of centres reported using morbidity and mortality conferences (96% vs. 97%, p = 0.61) and quality of care audits (94% vs. 88%, p = 0.08) while approximately half used report cards (51% vs. 43%, p = 0.22).ConclusionsTeaching and non-teaching centres reported being engaged in quality improvement and exhibited largely similar quality improvement activities. However, differences exist in the type and frequency of quality indicators utilized among teaching versus non-teaching trauma centres.

A study protocol for performance evaluation of a new academic intensive care unit facility: impact on patient care

Background Healthcare facility construction is increasing because of population demand and the need to replace ageing infrastructure. Research suggests that there may be a relationship between healthcare environment and patient care. To date, most evaluations of new healthcare facilities are derived from techniques used in other industries and focus on physical, financial and architectural performance. However, few studies have evaluated the impact of healthcare facility design on processes and outcomes of patient care. Study aims The primary objective of this study was to investigate the impact of relocation to a new intensive care unit (ICU) facility on clinical performance measures. This study also proposes to develop and test a framework for facility performance evaluation using accepted ICU design guidelines and Donabedians model for healthcare quality. Methods and analysis We will utilise a mixed-methods, observational, retrospective, controlled, before-and-after design to take advantage of the quasiexperimental conditions created with the construction of a new ICU facility in Calgary, Canada. For the qualitative substudy, we will conduct individual interviews with end-users to understand their impressions and experiences with the new environment and perform thematic analysis. For the quantitative substudy, we will compare process of care indicators and patient outcomes for the 12-month period before and after relocation to the new facility. Two other local ICU facilities that did not undergo structural change during the study period will serve as controls. We will triangulate qualitative and quantitative results utilising a novel framework. Ethics and dissemination The results of this study will contribute in understanding the impact of new ICU facilities on clinical performance measures centred on patients, their families and healthcare providers. The framework will complement existing building performance evaluation techniques and help healthcare administrators plan new ICU facilities. The University of Calgary Research Ethics Board approved this study protocol.

Implementation of an evidence-based feeding guideline did not reduce mortality in intensive care units

Question Does implementation of an evidence-based nutritional support guideline improve feeding practices and reduce mortality in patients in intensive care units (ICUs)? Methods Design Cluster-randomized controlled trial. Australian New Zealand Trials Registry. ACTRN12608000407392. Allocation Concealed.* Blinding Unblinded.* Follow-up period 20 weeks (individual patients were followed until death or hospital discharge). Setting 27 level II or III ICUs in Australia and New Zealand. Patients 1118 adults (mean age 59 y, 61% men) who were recently admitted to the ICU and expected to stay >2 days and were not tolerating an oral diet. Palliative care, moribund, or brain-dead patients and those admitted from another ICU were excluded. Intervention Development and implementation of a nutrition guideline (14 ICUs, 561 patients) or maintenance of usual feeding protocols (13 ICUs, 557 patients). The intensive care specialist and dietitian coinvestigators from each intervention ICU participated in a 2-day conference to develop the evidence-based feeding guideline. Physicians and staff at intervention ICUs were exposed to a multifaceted practice change strategy, including lectures, individual encouragement, active and passive reminders, and feedback. Outcomes ICU and hospital mortality and length of stay, and process measures. Patient follow-up 100% (intention-to-treat analysis). Main results The guideline intervention increased the proportion of ICU patients receiving nutritional support (95% vs 73%, P <0.001) and fed within 24 hours of admission (61% vs 37%, P <0.001), reduced mean time to first parenteral feeding (1.0 vs 1.4 d, P =0.04) and first enteral feeding (0.8 vs 1.4 d, P <0.001), and increased mean proportion of days in the ICU that patients were fed (81% vs 69%, P =0.002). Groups did not differ for mortality or length of stay (Table). Conclusion A multifaceted practice change strategy to implement an evidence-based nutritional support guideline improved feeding practices in intensive care units but did not reduce mortality. Implementation of an evidence-based feeding guideline vs usual feeding protocols in intensive care units (ICUs) Outcomes Guideline group Control group Difference (95% CI) ICU mortality 25% 22% 3.0% (3.2 to 10) Hospital mortality 29% 27% 1.4% (6.3 to 12) Mean ICU stay (d) 9.1 9.9 0.9 (2.6 to 1.3) Mean hospital stay (d) 24 24 0.1 (3.8 to 4.4) CI defined in Glossary. Commentary Nutritional support is an important therapeutic intervention for critically ill patients, with a large evidence base of randomized controlled trials (RCTs). Previous cluster RCTs evaluating nutrition guidelines have shown variable effects on patient outcomes (1, 2). Doig and colleagues evaluated a guideline promoting early nutrition (<24 h after admission) and achievement of 80% of nutritional requirements by 72 hours. The guideline emphasizes strategies to maximize enteral nutrition over starting parenteral nutrition if requirements are not rapidly met, similar to another recent guideline (2). Strengths of the trial include well-described guideline development methods, a multifaceted implementation program, and rigorous cluster RCT methods and reporting. The trial found improved nutritional practices, but not clinical outcomes, in the intervention group. Reasons for these disappointing results may include better feeding practices in the control group compared with previous reports (13), reflecting secular improvements; specific local barriers to guideline uptake that might have reduced the effect of the intervention at some sites; and a smaller true effect of the intervention than the RCT was powered to detect. Given these limitations, strategies to improve adherence to nutrition guidelines are still worthwhile and should not be abandoned, particularly in ICUs in which feeding practices are worse than those studied. Improving clinical outcomes from nutrition interventions may also require novel therapies (such as antioxidants, which are currently undergoing evaluation in RCTs), flexible guideline implementation strategies tailored to overcome local barriers, and an ongoing commitment to conduct high-quality evaluations of these strategies in cluster RCTs such as this one, guided by knowledge of baseline nutrition support practices in the ICUs studied.