Michelle E. Kho

Safety Climate Survey: reliability of results from a multicenter ICU survey

Background: It is important to understand the clinical properties of instruments used to measure patient safety before they are used in the setting of an intensive care unit (ICU). Methods: The Safety Climate Survey (SCSu), an instrument endorsed by the Institute for Healthcare Improvement, the Safety Culture Scale (SCSc), and the Safety Climate Mean (SCM), a subset of seven items from the SCSu, were administered in four Canadian university affiliated ICUs. All staff including nurses, allied healthcare professionals, non-clinical staff, intensivists, and managers were invited to participate in the cross sectional survey. Results: The response rate was 74% (313/426). The internal consistency of the SCSu and SCSc was 0.86 and 0.80, respectively, while the SCM performed poorly at 0.51. Because of poor internal consistency, no further analysis of the SCM was therefore performed. Test-retest reliability of the SCSu and SCSc was 0.92. Out of a maximum score of 5, the mean (SD) scores of the SCSu and SCSc were 3.4 (0.6) and 3.4 (0.7), respectively. No differences were noted between the three medical-surgical and one cardiovascular ICU. Managers perceived a significantly more positive safety climate than other staff, as measured by the SCSu and SCSc. These results need to be interpreted cautiously because of the small number of management participants. Conclusions: Of the three instruments, the SCSu and SCSc appear to be measuring one construct and are sufficiently reliable. Future research should examine the properties of patient safety instruments in other ICUs, including responsiveness to change, to ensure that they are valid outcome measures for patient safety initiatives.

Process description and evaluation of Canadian Physical Activity Guidelines development

BackgroundThis paper describes the process used to arrive at recommended physical activity guidelines for Canadian school-aged children and youth (5-17 years), adults (18-64 years) and older adults (≥65 years).MethodsThe Canadian Society for Exercise Physiology (CSEP) Physical Activity Measurement and Guidelines (PAMG) Steering Committee used the Appraisal of Guidelines for Research Evaluation (AGREE II) Instrument to inform the guideline development process. Fourteen background papers and five systematic reviews were completed. Systematic review authors appraised and synthesized the data, and proposed specific recommendations at an international consensus conference of invited experts and key stakeholders. Independently, an international panel of experts interpreted the evidence from the systematic reviews and developed recommendations following attendance at the Consensus Conference.ResultsUsing the AGREE II instrument as a guide, specific foci for each of the guidelines were defined and systematic review methodology was used to synthesize the evidence base. The expert panel, CSEP PAMG Steering Committee and methodological consultants reviewed the systematic reviews and Consensus Statement. The expert panel achieved consensus on the level of evidence informing the physical activity guidelines and developed a separate document outlining key recommendations, interpretation of the evidence and justification of each recommendation.ConclusionThe CSEP and Public Health Agency of Canada followed a rigorous process to examine the evidence informing potential revisions to existing physical activity guidelines for Canadians. It is believed that this is the first physical activity guideline development process in the world to be guided and assessed by AGREE II and AMSTAR instruments.

The Completeness of Reporting (CORE) index identifies important deficiencies in observational study conference abstracts

OBJECTIVE The aim was to develop, test, and apply an index to assess the completeness of reporting in a cohort of observational studies of conference abstracts. STUDY DESIGN AND SETTING Using rigorous methods, we reduced 245 items generated by literature review to 48 candidate items. In a random sample of 30 conference abstracts of rituximab for nonHodgkin lymphoma, we developed an item impact score using a survey of abstract stakeholders combined with the prevalence of each of the 48 items. We retained 14 independent items representing completeness of reporting, the CORE-14. Two raters determined the reliability of the instrument. We then applied the CORE-14 in another 78 studies to determine the prevalence of each feature. RESULTS Our survey response rate was 83.9% (47/56). Interrater reliability (95% CI) of the CORE-14 instrument was 0.56 (0.25, 0.77), which improved by averaging across scores provided by two raters (0.72 [0.49, 0.86]). Applying the CORE-14 in an additional set of 78 abstracts, six items occurred > or =85% and four items occurred < or =40% of the time. CONCLUSION Opportunities to improve conference abstract reporting exist. This scale could guide future conference abstract submissions and aid individuals considering conference abstract data to inform clinical practice, systematic reviews, guidelines, or policy.

Barriers and facilitators of thromboprophylaxis for medical-surgical intensive care unit patients: a multicenter survey.

BACKGROUND The objective of this study was to identify the self-reported barriers to and facilitators of prescribing low-molecular-weight heparin (LMWH) thromboprophylaxis in the intensive care unit (ICU). METHODS We conducted an interviewer-administered survey of 4 individuals per ICU (the ICU director, a bedside pharmacist, a thromboprophylaxis research coordinator, and physician site investigator) regarding LMWH thromboprophylaxis for medical-surgical patients in 27 ICUs in Canada and the United States. Items were generated by the research team and adapted from previous surveys, audits, qualitative studies, and quality improvement research. Respondents rated the barriers to LMWH use, facilitators (effectiveness, affordability, and acceptability thereof), and perceptions regarding LMWH use. RESULTS Respondents had 14.5 (SD, 7.7) years of ICU experience (response rate, 99%). The 5 most common barriers in descending order were as follows: drug acquisition cost, fear of bleeding, lack of resident education, concern about bioaccumulation in renal failure, and habit. The top 5 rated facilitators were preprinted orders, education, daily reminders, audit and feedback, and local quality improvement committee endorsement. Centers using preprinted orders (mean difference [P<.01]) and computerized physician order entry (P<.01) compared with those centers not using those tools reported higher affordability for these 2 facilitators. Compared with physicians and pharmacists, research coordinators considered ICU-specific audit and feedback of thromboprophylaxis rates to be a more effective, acceptable, and affordable facilitator (odds ratio, 6.67; 95% confidence interval, 1.97-22.53; P<.01). Facilitator acceptability ratings were similar within centers but differed across centers (P≤.01). CONCLUSIONS This multicenter survey found several barriers to use of LMWH including cost, concern about bleeding, and lack of resident knowledge of effectiveness. The diversity of reported facilitators suggests that large scale programs may address generic barriers but also need site-specific interprofessional knowledge translation activities.

Recruitment of multiple stakeholders to health services research: Lessons from the front lines

BackgroundSelf-administered surveys are an essential methodological tool for health services and knowledge translation research, and engaging end-users of the research is critical. However, few documented accounts of the efforts invested in recruitment of multiple different stakeholders to one health services research study exist. Here, we highlight the challenges of recruiting key stakeholders (policy-makers, clinicians, guideline developers) to a Canadian Institutes of Health Research (CIHR) funded health services research (HSR) study aimed to develop an updated and refined version of a guideline appraisal tool, the AGREE.MethodsUsing evidence-based methods of recruitment, our goal was to recruit 192 individuals: 80 international guideline developers, 80 Canadian clinicians and 32 Canadian policy/decision-makers. We calculated the participation rate and the recruitment efficiency.ResultsWe mailed 873 invitation letters. Of 838 approached, our participation rate was 29%(240) and recruitment efficiency, 19%(156). One policy-maker manager did not allow policy staff to participate in the study.ConclusionsBased on the results from this study, we suggest that future studies aiming to engage similar stakeholders in HSR over sample by at least 5 times to achieve their target sample size and allow for participant withdrawals. We need continued efforts to communicate the value of research between researchers and end-users of research (policy-makers, clinicians, and other researchers), integration of participatory research strategies, and promotion of the value of end-user involvement in research. Future research to understand methods of improving recruitment efficiency and engaging key stakeholders in HSR is warranted.

Cross-cultural adaptation and psychometric testing of the Arabic version of the Patient-Rated Wrist Hand Evaluation (PRWHE-A) in Saudi Arabia

PURPOSES The purposes of this study was to 1) perform a cross-cultural Arabic translation for the Patient-Rated Wrist and Hand Evaluation (PRWHE-A) using standardized guidelines and, 2) to test the psychometrics properties of the translated measure. METHODS A total of 48 patients with variety of hand disabilities, a mean age of 47 ± 16 years were recruited and assessed two times. The intraclass correlation coefficient (ICC) was used for assessing test-retest reliability of the PRWHE-A and its subscales while Cronbachs alpha (CA) was used for assessing the internal consistency. Construct validity was assessed by examining the strength of the correlation between the PRWHE-A and the Arabic version of the Disability of the Arm, Shoulder and Hand (DASH-A). RESULTS The PRWHE-A demonstrated excellent test-retest reliability (ICC= 0.97) and internal consistency (CA= 0.96). The DASH-A demonstrated moderately to low correlation (r= 0.64) with the PRWHE-A. CONCLUSIONS The results of this study indicated that PRWHE-A is a reliable and valid assessment tool and can be used in patients with different wrist/hand disabilities whose primary language is Arabic.

Outcome Measures in Clinical Practice: Five Questions to Consider When Assessing Patient Outcome

The use of outcome measures (OMs) in clinical practice has become increasingly important, due to the expectations to account for patient outcomes and justify healthcare expenditures. With the ability to assess patients’ current status and change over time, OMs can inform clinical decision-making and help clinicians and patients better understand their current function and projected recovery. When assessing outcomes, there are five key considerations for clinicians: confidence in a measured value; the extent to which valid inferences can be drawn from a measured value; the extent to which valid inferences concerning a patient’s change status can be made; the patient specific target value; and the ideal reassessment interval. The purpose of this paper is to provide a guide to help clinicians to choose and effectively utilize OMs. We will address the five important application questions to consider, illustrated with clinical examples using the 6-min walk test in different patient populations.

The impact of rehabilitative interventions on quality of life: a qualitative evidence synthesis of personal experiences of individuals with amyotrophic lateral sclerosis

BackgroundThe nature of amyotrophic lateral sclerosis (ALS) is progressive and degenerative, thus influencing individuals physically, emotionally, and socially. A broad review of qualitative studies that describe the personal experiences of people with ALS with physiotherapy, occupational therapy and speech and language pathology interventions, and how those affect QoL is warranted.PurposeThis study synthesizes qualitative research regarding the potential that rehabilitation interventions have to maintain and/or improve QoL from the perspective of people with ALS.MethodsThe SPIDER search strategy was applied and five articles met inclusion criteria addressing the perceived impact of rehabilitation on QoL for individuals with ALS.ResultsFour themes emerged: the concept of control; adapting interventions to disease stage; struggles with interventions; and barriers between healthcare providers and patients.ConclusionsRehabilitation interventions were perceived to have potential to support QoL by people with ALS. Advantages and limitations of rehabilitation services within this population were identified.

Barriers and facilitators to early rehabilitation in mechanically ventilated patients—a theory-driven interview study

BackgroundDespite a supportive evidence base and a push to implement, the uptake of early rehabilitation in critical care has been inconsistent. The objective of this study was to explore barriers and facilitators to early rehabilitation for critically ill patients receiving invasive mechanical ventilation.MethodsUsing the Theoretical Domains Framework (TDF) of behavior change, we conducted semi-structured interviews exploring barriers and facilitators to early rehabilitation among four purposively sampled ICU clinician groups (nurses, rehabilitation professionals, respiratory therapists, and physicians). The TDF is a comprehensive framework of 14 “construct domains,” synthesized from 33 theories of behavior that was developed to study determinants of behavior and to design interventions to improve evidence-based healthcare practice. A topic guide was developed and piloted based on the TDF and expert knowledge. Interviews were audio-recorded and transcribed verbatim. Transcripts were content analyzed by coding items into domains and then synthesized into more specific, over-arching themes or “beliefs.” An expert consensus group used structured decision rules to classify beliefs as high, moderate, or low in importance.ResultsWe interviewed 40 stakeholders from the four clinician groups and identified 135 separate beliefs. Of these, 19 were classified as high, 40 as moderate, and 76 of low importance as barriers or facilitators. All beliefs classified as highly important fell within one of seven TDF domains: skills, social/professional role and identity, beliefs about capabilities, beliefs about consequences, environmental context/resources, social influences, and behavioral regulation. Beliefs of lower importance fell under the following seven domains: knowledge; optimism; reinforcement; intention; goals; memory, attention, and decision processes; and emotion. Quantitative differences in stated beliefs about early rehabilitation between professional groups were not common.ConclusionsThis study identified important barriers and facilitators to early rehabilitation in critical care patients. Domains identified as important should be considered when designing interventions to increase uptake of early rehabilitation.

Physiotherapy in the neurotrauma intensive care unit: A scoping review

Purpose: This scoping review summarizes the literature on the safety and effectiveness of physiotherapy interventions in patients with neurological and/or traumatic injuries in the intensive care unit (ICU), identifies literature gaps and provides recommendations for future research. Materials and methods: We searched five databases from inception to June 2, 2018. We included published retrospective studies, case studies, observation and randomized controlled trials describing physiotherapy interventions in ICU patients with neurotrauma injuries. Two reviewers reviewed the databases and independently screened English articles for eligibility. Data extracted included purpose, study design, population (s), outcome measures, interventions and results. Thematic analysis and descriptive numerical summaries are presented by intervention type. Results: 12,846 titles were screened and 72 met the inclusion criteria. Most of the studies were observational studies (44 (61.1%)) and RCTs (14 (19.4%)). Early mobilization, electrical stimulation, range of motion, and chest physiotherapy techniques were the most common interventions in the literature. Physiotherapy interventions were found to be safe with few adverse events. Conclusions: Gaps in the literature suggest that future studies require assessment of long term functional outcomes and quality of life, examination of homogenous populations and more robust methodologies including clinical trials and larger samples.