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Introduction: Medical advancements are slow to reach the patient bedside due to issues with knowledge translation from preclinical studies. Multi-laboratory preclinical studies are a promising strategy for addressing the methodological deficiencies that weaken the translational impact of single laboratory findings. However, multi-laboratory preclinical studies are rare and difficult, requiring strong collaboration to plan and execute a shared protocol. In multiteam systems such as these, collaboration is enhanced when members have cohesive ways of thinking about their goals and how to achieve them–that is, when they have "shared mental models". In this research project, we will examine how members of Canada's first multi-laboratory preclinical study build shared mental models and collaborate in the execution of their study. Methods: Six independent labs in Canada will conduct a preclinical study using a common protocol. To investigate mental models and collaboration in this multiteam system we will conduct a longitudinal qualitative study involving interviews at four time points, team observation, and document analysis. We will analyze interview transcripts using deductive coding to produce a matrix analysis of mental model content over time and inductive coding to produce a thematic analysis of members' experiences of collaboration over time. We will also triangulate data sources to "tell the story" of teamwork, capturing events and contextual information that explain changes in mental models and collaboration over time. Discussion: This study will be one of the most comprehensive longitudinal analyses of a real-world multiteam system, and the first within a preclinical laboratory setting. The results will contribute to our understanding of collaboration in multiteam systems, an organizational form increasingly used to tackle complex scientific and social problems. The results will also inform the implementation of future multi-laboratory preclinical studies, enhancing the likelihood of effective collaboration and improved 'bench to bedside' translation. [ABSTRACT FROM AUTHOR]

Importance: There is marked variability in red blood cell (RBC) transfusion during the intraoperative period. The development and implementation of existing clinical practice guidelines have been ineffective in reducing this variability., Objective: To develop an internationally endorsed consensus statement about intraoperative transfusion in major noncardiac surgery., Evidence Review: A Delphi consensus survey technique with an anonymous 3-round iterative rating and feedback process was used. An expert panel of surgeons, anesthesiologists, and transfusion medicine specialists was recruited internationally. Statements were informed by extensive preparatory work, including a systematic reviews of intraoperative RBC guidelines and clinical trials, an interview study with patients to explore their perspectives about intraoperative transfusion, and interviews with physicians to understand the various behaviors that influence intraoperative transfusion decision-making. Thirty-eight statements were developed addressing (1) decision-making (interprofessional communication, clinical factors, procedural considerations, and audits), (2) restrictive transfusion strategies, (3) patient-centred considerations, and (4) research considerations (equipoise, outcomes, and protocol suspension). Panelists were asked to score statements on a 7-point Likert scale. Consensus was established with at least 75% agreement., Findings: The 34-member expert panel (14 of 33 women [42%]) included 16 anesthesiologists, 11 surgeons, and 7 transfusion specialists; panelists had a median of 16 years' experience (range, 2-50 years), mainly in Canada (52% [17 of 33]), the US (27% [9 of 33]), and Europe (15% [5 of 33]). The panel recommended routine preoperative and intraoperative discussion between surgeons and anesthesiologists about intraoperative RBC transfusion as well as postoperative review of intraoperative transfusion events. Point-of-care hemoglobin testing devices were recommended for transfusion guidance, alongside an algorithmic transfusion protocol with a restrictive hemoglobin trigger; however, more research is needed to evaluate the use of restrictive triggers in the operating room. Expert consensus recommended a detailed preoperative consent discussion with patients of the risks and benefits of both anemia and RBC transfusion and routine disclosure of intraoperative transfusion. Postoperative morbidity and mortality were recommended as the most relevant outcomes associated with intraoperative RBC transfusion, and transfusion triggers of 70 and 90 g/L were considered acceptable hemoglobin triggers to evaluate restrictive and liberal transfusion strategies, respectively, in clinical trials., Conclusions and Relevance: This consensus statement offers internationally endorsed expert guidance across several key domains on intraoperative RBC transfusion practice for noncardiac surgical procedures for which patients are at medium or high risk of bleeding. Future work should emphasize knowledge translation strategies to integrate these recommendations into routine clinical practice and transfusion research activities.

Purpose: Understanding which outcomes matter most and improving outcomes for the growing population of older surgical patients are top priorities for Canadian anesthesia research. Nevertheless, there is little understanding of which outcomes older surgical patients prioritize most highly. We evaluated how older people prioritized six outcomes after elective noncardiac surgery. These outcomes were recommended in core outcome sets for perioperative medicine., Methods: Following ethical approval, we conducted a prospective, nested, cross-sectional study of people one year after they had major elective noncardiac surgery. Participants were asked to rate the importance of six commonly measured outcomes (complications, length of stay, discharge disposition, days at home, disability score, and developing a new disability) on an 11-point Likert scale. Open-ended questions elicited other preferences. Pairwise comparisons were evaluated using Bayesian multivariate regression. K-means clustering identified subgroups of patients based on overall prioritization. Thematic analysis was applied to open-ended responses., Results: One hundred and one consecutive participants responded. All outcomes scored at least 7.7/10 on average. Complications and discharge location were most highly rated, but only days at home and length of stay had substantial probability (> 99%) of being rated lower than the other four outcomes. Thematic analysis identified the need for greater procedure-specific information, support services, and physical recovery measures., Conclusions: Commonly recorded and recommended outcomes are reassuringly relevant to older people; however, system-related measures are less highly valued than those more directly related to health and function. Outcomes may need to be personalized to properly evaluate the success of perioperative care., (© 2022. Canadian Anesthesiologists' Society.)

Objective: To determine if virtual care with remote automated monitoring (RAM) technology versus standard care increases days alive at home among adults discharged after non-elective surgery during the covid-19 pandemic., Design: Multicentre randomised controlled trial., Setting: 8 acute care hospitals in Canada., Participants: 905 adults (≥40 years) who resided in areas with mobile phone coverage and were to be discharged from hospital after non-elective surgery were randomised either to virtual care and RAM (n=451) or to standard care (n=454). 903 participants (99.8%) completed the 31 day follow-up., Intervention: Participants in the experimental group received a tablet computer and RAM technology that measured blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, and body weight. For 30 days the participants took daily biophysical measurements and photographs of their wound and interacted with nurses virtually. Participants in the standard care group received post-hospital discharge management according to the centre's usual care. Patients, healthcare providers, and data collectors were aware of patients' group allocations. Outcome adjudicators were blinded to group allocation., Main Outcome Measures: The primary outcome was days alive at home during 31 days of follow-up. The 12 secondary outcomes included acute hospital care, detection and correction of drug errors, and pain at 7, 15, and 30 days after randomisation., Results: All 905 participants (mean age 63.1 years) were analysed in the groups to which they were randomised. Days alive at home during 31 days of follow-up were 29.7 in the virtual care group and 29.5 in the standard care group: relative risk 1.01 (95% confidence interval 0.99 to 1.02); absolute difference 0.2% (95% confidence interval -0.5% to 0.9%). 99 participants (22.0%) in the virtual care group and 124 (27.3%) in the standard care group required acute hospital care: relative risk 0.80 (0.64 to 1.01); absolute difference 5.3% (-0.3% to 10.9%). More participants in the virtual care group than standard care group had a drug error detected (134 (29.7%) v 25 (5.5%); absolute difference 24.2%, 19.5% to 28.9%) and a drug error corrected (absolute difference 24.4%, 19.9% to 28.9%). Fewer participants in the virtual care group than standard care group reported pain at 7, 15, and 30 days after randomisation: absolute differences 13.9% (7.4% to 20.4%), 11.9% (5.1% to 18.7%), and 9.6% (2.9% to 16.3%), respectively. Beneficial effects proved substantially larger in centres with a higher rate of care escalation., Conclusion: Virtual care with RAM shows promise in improving outcomes important to patients and to optimal health system function., Trial Registration: ClinicalTrials.gov NCT04344665., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/disclosure-of-interest/ and declare: support from Roche, McMaster University, the Research Institute of St Joseph’s Healthcare Hamilton, Ottawa Hospital Academic Medical Association, Queen’s University, Hamilton Health Sciences, Kingston Health Sciences, London Health Sciences, St Joseph’s Healthcare Hamilton, the Ottawa Hospital, and the University of Alberta Hospital for the submitted work; a financial relationship with Cloud Diagnostics Canada for purchase of devices and data plans used in this trial; and a relationship with Cloud Diagnostics Canada, which undertook training sessions for virtual nurses and perioperative doctors and surgeons on how to use their technology., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The Canadian Cardiovascular Society (CCS) guidelines for patients undergoing non-cardiac surgery address the lack of standardized management for patients at risk of perioperative cardiovascular complications. Our interdisciplinary group evaluated the implementation of these guidelines., Methods: We used an interrupted time series design to evaluate the effect of implementation of the CCS guidelines, using routinely collected hospital data. The study population consisted of elective, non-cardiac surgery patients who were: i) inpatients following surgery and ii) age ≥ 65 or age 45-64 yr with a Revised Cardiac Risk Index ≥ 1. Outcomes included adherence to troponin I (TnI) monitoring (primary) and adherence to appropriate consultant care for patients with elevated TnI (secondary). Exploratory outcomes included cost measures and clinical outcomes such as length of stay., Results: We included 1,421 patients (706 pre- and 715 post-implementation). We observed a 67% absolute increase (95% confidence interval, 55 to 80; P < 0.001) in adherence to TnI testing following the implementation of the guidelines. In patients who had elevated TnI following guideline implementation (n = 64), the majority (85%) received appropriate follow-up care in the form of a general medicine or cardiology consult, all received at least one electrocardiogram, and half received at least one advanced cardiac test (e.g., cardiac perfusion scan, or percutaneous intervention)., Conclusions: Our study showed the ability to implement and adhere to the CCS guidelines. Large-scale multicentre evaluations of CCS guideline implementation are needed to gain a better understanding of potential effects on clinically relevant outcomes., (© 2021. Canadian Anesthesiologists' Society.)

Objectives: The objective of the study was to assess the impact of narrative review (NR) vs. systematic review (SR) on expert assessments of a clinical trial., Study Design and Setting: Experts in colon and rectal surgery were randomized to read an NR or SR for an ongoing clinical trial involving surgery for colorectal cancer. Experts from the United States and Canada completed online or paper surveys between December 2018 and June 2019. After reading the NR or SR, experts predicted the trial's outcome and evaluated the trial under a hypothetical ethical review., Results: Experts who read the NR (n = 55) compared with those who read the SR (n = 56) were more likely to predict a higher absolute risk reduction, 58% vs. 33%, P = 0.018, mean predictions 10.6% vs. 6.6%, mean difference 4.0% [95% confidence interval: 0.3%, 7.8%]. Experts who read the NR were more likely to evaluate the trial more favorably under a hypothetical ethical review, 48% vs. 26%, P = 0.039, 20.0% vs. 8.9% "strongly in favor" of trial being pursued., Conclusion: An NR and an SR for the same trial led to different judgments of likely outcomes and ethical appropriateness. These differences point to a potential source of unaddressed bias in ethical review., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: Bench to bedside translation of groundbreaking treatments like chimeric antigen receptor T (CAR-T) cell therapy depends on patient participation in early phase trials. Unfortunately, many novel therapies fail to be adequately evaluated due to low recruitment rates, which slows patient access to emerging treatments. Using the Theoretical Domains Framework (TDF), we sought to identify potential patient barriers and enablers to participating in an early phase CAR-T cell therapy trial., Design: We used qualitative semistructured interviews to identify potential barriers and enablers to patients' hypothetical participation in an early phase CAR-T cell therapy trial. We used the TDF and directed content analysis to identify relevant domains based on frequency, relevance and the presence of conflicting beliefs., Participants: Canadian adult patients diagnosed with haematological malignancies., Results: In total, we interviewed 13 participants (8 women, 5 men). Participants ranged in age from 18 to 73 (median=56) and had been living with haematological cancer from a few months to several years. We found participants were unfamiliar with CAR-T cell therapy but wished to know more about treatment safety, efficacy and trial logistics (domains: knowledge, beliefs about consequences). They were motivated by altruistic considerations, though many prioritised personal health benefits despite recognising the goals (ie, establishing safety) of early phase clinical trials (domains: goals, intentions). Every participant valued receiving medical advice from their haematologists and oncologists, though some preferred impartial medical experts to inform their decision making (domain: social influences). Finally, participants indicated that improving access to financial and social supports would improve their trial participation experience (domain: environmental context and resources)., Conclusion: Using the TDF allowed us to identify factors that might undermine participation to a CAR-T cell therapy trial and to optimise recruitment processes by considering patient perspectives to taking part in early phase trials. Trial regestration: NCT03765177; Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: After nonelective (i.e., semiurgent, urgent and emergent) surgeries, patients discharged from hospitals are at risk of readmissions, emergency department visits or death. During the coronavirus disease 2019 (COVID-19) pandemic, we are undertaking the Post Discharge after Surgery Virtual Care with Remote Automated Monitoring Technology (PVC-RAM) trial to determine if virtual care with remote automated monitoring (RAM) compared with standard care will increase the number of days adult patients remain alive at home after being discharged following nonelective surgery., Methods: We are conducting a randomized controlled trial in which 900 adults who are being discharged after nonelective surgery from 8 Canadian hospitals are randomly assigned to receive virtual care with RAM or standard care. Outcome adjudicators are masked to group allocations. Patients in the experimental group learn how to use the study's tablet computer and RAM technology, which will measure their vital signs. For 30 days, patients take daily biophysical measurements and complete a recovery survey. Patients interact with nurses via the cellular modem-enabled tablet, who escalate care to preassigned and available physicians if RAM measurements exceed predetermined thresholds, patients report symptoms, a medication error is identified or the nurses have concerns they cannot resolve. The primary outcome is number of days alive at home during the 30 days after randomization., Interpretation: This trial will inform management of patients after discharge following surgery in the COVID-19 pandemic and offer insights for management of patients who undergo nonelective surgery in a nonpandemic setting. Knowledge dissemination will be supported through an online multimedia resource centre, policy briefs, presentations, peer-reviewed journal publications and media engagement., Trial Registration: ClinicalTrials.gov, no. NCT04344665., Competing Interests: Competing interests: CloudDX undertook training sessions for study nurses, perioperative physicians and surgeons regarding how to use their technology. David Conen has received personal fees from Servier Canada, outside of the current work. Emil Schemitsch has received personal fees from Stryker, Smith & Nephew, ITS Implants, Acumed, Swemac and DePuy Synthes, outside the present work. Emilie Belley-Cote has received grants from Bayer and Roche, outside the present work. Richard Whitlock has received grants from Bayer, Roche and Boehringer Ingelheim, an honorarium from Boehringer Ingeheim and consulting fees from AtriCure and PhaseBio, outside the present work. P.J. Devereaux has received a grant from Roche Diagnostics for the present work and grants from Abbott Diagnostics, Boehringer Ingeheim, Roche Diagnostics and Siemens, outside the present work, as well as patient monitors from Philips Healthcare and troponin assays from Siemens, outside the present work., (© 2021 Joule Inc. or its licensors.)