Victoria A. McCredie

Changes in end of life care 5 years after the introduction of a rapid response team: A multicentre retrospective study

RATIONALE Rapid response teams (RRTs) are intended to stabilize deteriorating patients on the ward, but recent studies suggest that RRTs may also improve end-of-life care (EOLC). We sought to study the effect of introducing an RRT on EOLC at our institutions, and compare the EOLC care received by patients who were consulted by the RRT with that of patients who were not consulted by the RRT. METHODS Retrospective review of 450 consecutive deaths at 3 institutions. We compared demographic factors and EOLC received before (2005) and 5 years after (2010) the introduction of an RRT. We also compared these same factors for patients who died in 2010 with and without RRT consultation. RESULTS There were no differences in the proportion of patients who had Patient/Family Conferences or orders to limit life support on the ward between 2005 and 2010. Although the RRT was consulted for 30% of patients eligible to be seen by the RRT, the RRT was involved in only 11.1% of Patient/Family Conferences that took place on the ward. The prevalence of palliative care consultation and orders for opioids as needed was higher in 2010 than 2005, but those seen by the RRT were less likely to receive a palliative care consultation (30.2% vs. 55.9%), spiritual care consultation (25.4% vs. 41.3%) or an order for sedatives as needed (44.4% vs. 65.0%) than those who were not seen by the RRT. There was no change in the proportion of patients admitted to the ICU in 2010 compared with 2005, and multivariable logistic regression showed that the year of death did not influence the likelihood of ICU admission based on any comorbid or demographic factors. CONCLUSIONS The introduction of an RRT was not associated with significant improvements in EOLC at our institutions. However, almost 1/3 of dying patients were consulted by the RRT, suggesting that the RRT could play a role in facilitating improved EOLC for some inpatients.

Beta-blockers and Traumatic Brain Injury: A Systematic Review, Meta-analysis, and Eastern Association for the Surgery of Trauma Guideline

OBJECTIVE To determine if beta-(β)-blockers improve outcomes after acute traumatic brain injury (TBI).Objective: To determine if beta-(&bgr;)-blockers improve outcomes after acute traumatic brain injury (TBI). Background: There have been no new inpatient pharmacologic therapies to improve TBI outcomes in a half-century. Treatment of TBI patients with &bgr;-blockers offers a potentially beneficial approach. Methods: Using MEDLINE, EMBASE, and CENTRAL databases, eligible articles for our systematic review and meta-analysis (PROSPERO CRD42016048547) included adult (age ≥ 16 years) blunt trauma patients admitted with TBI. The exposure of interest was &bgr;-blocker administration initiated during the hospitalization. Outcomes were mortality, functional measures, quality of life, cardiopulmonary morbidity (e.g., hypotension, bradycardia, bronchospasm, and/or congestive heart failure). Data were analyzed using a random-effects model, and represented by pooled odds ratio (OR) with 95% confidence intervals (CI) and statistical heterogeneity (I2). Results: Data were extracted from 9 included studies encompassing 2005 unique TBI patients with &bgr;-blocker treatment and 6240 unique controls. Exposure to &bgr;-blockers after TBI was associated with a reduction of in-hospital mortality (pooled OR 0.39, 95% CI: 0.27–0.56; I2 = 65%, P < 0.00001). None of the included studies examined functional outcome or quality of life measures, and cardiopulmonary adverse events were rarely reported. No clear evidence of reporting bias was identified. Conclusions: In adults with acute TBI, observational studies reveal a significant mortality advantage with &bgr;-blockers; however, quality of evidence is very low. We conditionally recommend the use of in-hospital &bgr;-blockers. However, we recommend further high-quality trials to answer questions about the mechanisms of action, effectiveness on subgroups, dose-response, length of therapy, functional outcome, and quality of life after &bgr;-blocker use for TBI.

Timing of withdrawal of life-sustaining therapies in severe traumatic brain injury: Impact on overall mortality.

BACKGROUND The care of patients with severe traumatic brain injury (TBI) is complex and confounded by uncertainty in prognoses. Studies have demonstrated significant unexplained variation in mortality between centers. Possible explanations include differences in the quality and intensity of care across centers, including the appropriateness and timing of withdrawal of life-sustaining therapies. We postulated that centers with a preponderance of early deaths might have a more pessimistic approach to the TBI patient, which would be reflected in an increased hospital TBI-related mortality. METHODS This is a retrospective cohort study. Time to death was used as a proxy for time to withdrawal of life-sustaining therapies. Centers were classified as early or late based on when the majority (75th percentile) of their TBI-related deaths occurred. We evaluated the association between adjusted mortality and center classification using a hierarchical multivariable model. Two hundred trauma centers contributing data to the American College of Surgeons Trauma Quality Improvement Program from 2010 through 2013 were involved. The cohort included 17,505 patients with severe isolated TBI. RESULTS One hundred eight centers were classified as early centers. The 75th percentile for time to death was 4 days among early centers versus 7 days in late centers. Mortality was 34% and 33%, respectively. After adjustment for case mix, care in an early center was not associated with increased odds of death (adjusted odds ratio, 0.95; 95% confidence interval, 0.83–1.09). Higher odds of death were independently associated with age, Glasgow Coma Scale (GCS) score, head Abbreviated Injury Scale (AIS) score, multiple comorbidities, traumatic subarachnoid hemorrhage, intracerebral mass lesions, brainstem lesions, and signs of compressed or absent basal cisterns. CONCLUSION Centers rendering early decisions related to withdrawal of life-sustaining therapies in TBI patients, as measured by time until death, do not have worse outcomes than those making later decisions. How and when these decisions are made requires further exploration to balance an opportunity for clinical improvement with appropriate resource use. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

Does Sample Size Matter When Interpreting the Fragility Index

e1142 www.ccmjournal.org November 2016 • Volume 44 • Number 11 concept of the fragility index (FI), the minimum number of patients whose status would have to change from a nonevent to an event that is required to turn a statistically significant result to a nonsignificant result. Although the idea of reporting a fragility metric is not novel—Feinstein (2) proposed the “unit FI” in 1990—we have seen a renewed interest in this concept over the past few years (1, 3, 4). The stability of an observed statistically significant result can be difficult to quantify; a simplified and intuitive metric of a trial’s statistical fragility may enable a clearer interpretation of a trial’s results. However, the FI is an absolute measure of stability, irrespective of trial size, and we believe a relative measure referencing the FI to the trial sample size should be reported in tandem with the FI. A relative measure of fragility was actually incorporated into the original unit FI by Feinstein (2) and further explored by Walter (5). This approach requires, in addition to considering statistical significance and fragility, a subjective decision about the magnitude of effect to calculate the “quantitative significance.” This computational complexity may explain the lack of routine adoption since its inception in 1990, compared to the most recent simplification of the FI in 2014 (2, 4). Still, this concept is important as the effect size is often unstable in small trials. In addition, loss of patients to follow-up can undermine confidence in the significance of any effect, especially so as the number lost approaches the FI number. Consequently, we propose a simplified “relative” measure of fragility, the “fragility quotient (FQ)”: the absolute FI number divided by the total sample size. How would this work in practice? Consider two trials with a FQ of 0.1. The first trial has a sample size of 20 with one of 10 in the treatment arm dying versus eight of 10 in the placebo arm; the FI is 2. The second trial has 300 patients with 13 of 150 in the treatment arm dying versus 60 of 150 in the placebo arm; the FI is 30. The statistical significance of the results in both trials depends on two versus 30 events respectively, but the proportion of deaths is the same with a FQ of 0.1 for each study. Reporting the absolute number of events needed (FI) and a relative measure of fragility (FQ) might afford a fuller understanding of the fragility of a trial in the context of the overall sample size. The authors have disclosed that they do not have any potential conflicts of interest. The opinions, results, and conclusions reported in this article are those of the authors and are independent of funding sources.

Airway Management Strategies for Brain-injured Patients Meeting Standard Criteria to Consider Extubation. A Prospective Cohort Study

Rationale: Patients with acute brain injury are frequently capable of breathing spontaneously with minimal ventilatory support despite persistent neurological impairment. Objectives: We sought to describe factors associated with extubation timing, success, and primary tracheostomy in these patients. Methods: We conducted a prospective multicenter observational cohort study in three academic hospitals in Toronto, Canada. Consecutive brain‐injured adults receiving mechanical ventilation for at least 24 hours in three intensive care units were screened by study personnel daily for extubation consideration criteria. We monitored all patients until hospital discharge and used logistic regression models to examine associations with extubation failure and delayed extubation. Measurements and Main Results: Of 192 patients included, 152 (79%) were extubated and 40 (21%) received a tracheostomy without an extubation attempt. The rate of extubation failure within 72 hours was 32 of 152 (21%), which did not vary significantly between those extubated before (early; 6 of 37; 16.2%), within 24 hours (timely; 14 of 70; 20.0%), or more than 24 hours after meeting criteria to consider extubation (delayed; 12 of 45; 26.7%; P = 0.49). Delayed extubation was associated with lower a Glasgow Coma Scale (GCS) score at the time of consideration of extubation, absence of cough, and new positive sputum cultures. Factors independently associated with successful extubation were presence of cough (odds ratio [OR], 3.60; 95% confidence interval [CI], 1.42‐9.09), fluid balance in prior 24 hours (OR, 0.75 per 1‐L increase; 95% CI, 0.57‐0.98), and age (OR, 0.97 per 10‐yr increase; 95% CI, 0.95‐0.99). A higher GCS score was not associated with successful extubation. Conclusions: Extubation success was predicted by younger age, presence of cough, and negative fluid balance, rather than GCS score at extubation. These results do not support prolonging intubation solely for low GCS score in brain‐injured patients.

EEG utilization in Canadian intensive care units: A multicentre prospective observational study

PURPOSE We have previously shown that electroencephalography (EEG) may be an underutilized monitoring modality in a single general medical-surgical ICU, that does not have a specific neurocritical care consultation service or neurocritical care unit. The present study was designed to describe the pattern of EEG utilization across 3 academic ICUs in Ontario, Canada that use different models of neurocritical care. METHOD In this prospective multicentre observational study, ICU patients were screened weekly for 6 non-consecutive weeks to determine if they met the ESICMs recommendations or suggestions for EEG monitoring. If EEGs were performed, the results were recorded. Three models of neurocritical care provision were examined in 3 academic tertiary ICUs. Site 1 is an intensivist-led, medical-surgical ICU with no specific neurocritical care consultation service. The second site is also an intensivist led medical-surgical ICU, but with a formal neurocritical care consultation service. The third site is a virtual neurological and neurotrauma ICU within a medical-surgical ICU, staffed by rotating neurointensivists and general intensivists. RESULTS Of the 375 patients who were screened, 127 patients (34%) met at least one ESICM indication for EEG monitoring. Among the 127 patients, 46 patients (37%) had an EEG performed. Site 1 had the highest proportion of EEGs performed. The most common indication for EEG monitoring was for patients with unexplained altered level of consciousness, in the absence of primary brain injury. For the EEGs performed per ESICM indication, the majority of epileptiform abnormalities were found in patients admitted with status epilepticus. CONCLUSIONS EEG may be underutilized in Canadian ICUs. The impact on patient management and outcomes are unknown.

The use of standardized management protocols for critically ill patients with non-traumatic subarachnoid hemorrhage: a protocol of a systematic review and meta-analysis

BackgroundCaring for patients with subarachnoid hemorrhage (SAH) presents unique challenges, due in part to the severity of the underlying insult, competing systemic injuries, and unpredictable clinical course. Even when management occurs in dedicated critical care settings, treatment uncertainty often persists, and morbidity and mortality from the condition remain high. Complex decisions in SAH care may be simplified with the use of standardized management protocols (SMPs). SMPs incorporate evidence-based guidelines into a practical framework for decision-making, thereby providing clinicians with an algorithm for organizing treatments. But despite these potential advantages, it is currently unknown whether SMPs may improve outcomes in the critical care of patients with SAH.MethodsWe will conduct a systematic review of cohort studies and randomized control trials of adult patients with non-traumatic SAH who received care according to a standardized management protocol. Comprehensive search strategies will be developed for MEDLINE, EMBASE, WoS, CINAHL, and CENTRAL, to identify studies for review. The gray literature will be scanned for further eligible studies. Two reviewers will independently screen the material generated by the search to identify studies for inclusion. A standardized data extraction form will be used to collect information on study design, baseline characteristics, details of the management protocol employed, and primary and secondary outcomes. Where possible, meta-analyses with random-effects models will be used to calculate pooled estimates of effect sizes. Statistical heterogeneity will be evaluated with the I2 statistics, and risk of bias and reporting quality will be assessed independently and in duplicate with standardized scales.DiscussionWe anticipate a significant degree of clinical heterogeneity in our review, as protocols will likely vary in their content, implementation, and ICU setting. We will aim to summarize the current literature in this domain to understand if SMPs, as a low-cost process-targeted intervention, improve outcomes for critically ill patients with SAH. Our review will additionally inform future research endeavors to improve the processes of care for this patient population.Systematic review registrationCRD42017069173

Evaluating the effectiveness of the Emergency Neurological Life Support educational framework in low-income countries

Abstract Background The Emergency Neurological Life Support (ENLS) is an educational initiative designed to improve the acute management of neurological injuries. However, the applicability of the course in low-income countries in unknown. We evaluated the impact of the course on knowledge, decision-making skills and preparedness to manage neurological emergencies in a resource-limited country. Methods A prospective cohort study design was implemented for the first ENLS course held in Asia. Knowledge and decision-making skills for neurological emergencies were assessed at baseline, post-course and at 6 months following course completion. To determine perceived knowledge and preparedness, data were collected using surveys administered immediately post-course and 6 months later. Results A total of 34 acute care physicians from across Nepal attended the course. Knowledge and decision-making skills significantly improved following the course (p=0.0008). Knowledge and decision-making skills remained significantly improved after 6 months, compared with before the course (p=0.02), with no significant loss of skills immediately following the course to the 6-month follow-up (p=0.16). At 6 months, the willingness to participate in continuing medical education activities remained evident, with 77% (10/13) of participants reporting a change in their clinical practice and decision-making, with the repeated use of ENLS protocols as the main driver of change. Conclusions Using the ENLS framework, neurocritical care education can be delivered in low-income countries to improve knowledge uptake, with evidence of knowledge retention up to 6 months.

The Young Investigator Retreat of the Canadian Critical Care Trials Group: mentorship and self-discovery

The Canadian Critical Care Trials Group (CCCTG) was created in 1989 to improve the care of critically ill patients through investigator-initiated research and to provide a national forum for continuing education about research methods. In 2004, a group of clinical and basic scientists interested in the basic mechanisms of critical illness formed the Canadian Critical Care Translational Biology Group (CCCTBG). The two groups have grown from the original 25 participants in 1989 to over 300 researchers today. The CCCTG and CCCTBG meet together and currently support over 40 research programs with more than 100 peer-reviewed publications to their credit. The most important ingredients for this success are the collegiality and mentorship of these groups. A research mentor has many potential roles in developing the career of a young investigator, some of which include acting as advisor, advocate, coach, or supervisor, guiding the mentee with intent, commitment, and spirit. Given the need for sustainability and growth, the CCCTG and CCCTBG have an explicit mandate to mentor their junior and senior investigators and to foster their independent success. This mandate is addressed through several activities, including the ‘‘community mentoring’’ model of our thrice yearly meetings, explicit linkage between each young investigator who presents at these meetings and a CCCTG mentor, encouragement of junior members to participate in national committees, interdisciplinary young investigator grants, the Deborah J. Cook Mentorship Award to honour individuals who have made exceptional contributions in this domain, and the creation of the CCCTG Young Investigator Retreat. Dr. I. M. Ball, MD, MSc (&) Departments of Medicine, Epidemiology and Biostatistics, Western University, London, ON, Canada e-mail: Ian.Ball@lhsc.on.ca

Atraumatic (pencil-point) versus conventional needles for lumbar puncture: a clinical practice guideline

### What you need to know Is the needle tip configuration important when performing a lumbar puncture for any indication? A systematic review published in the Lancet in December 2017 suggests that it is. The review found that using atraumatic (pencil-point) lumbar puncture needles instead of conventional lumbar puncture needles reduced the risk of post-dural-puncture headache and of return to hospital for additional pain control.1 This guideline recommendation aims to promptly and transparently translate this evidence to a clinical recommendation, following standards for GRADE methodology and trustworthy guidelines.2 The BMJ Rapid Recommendations panel makes a strong recommendation for the use of atraumatic needles for lumbar puncture in all patients regardless of age (adults and children) or indication instead of conventional needles.34 Box 1 shows the article and evidence linked to this Rapid Recommendation. The main infographic provides an overview of the absolute benefits and harms (although none were present here) of atraumatic needles. Table 1 below shows any evidence that has emerged since the publication of this guideline. Box 1 ### Linked resources for this BMJ Rapid Recommendations clusterRETURN TO TEXT