Search

Background Indigenous Peoples experience health inequities across the continuum of health services. Improvements for Indigenous patients and their families during vulnerable experiences with the healthcare system may have a significant impact on the patient experience and outcomes. Improved understanding of the occurrence of critical illness in Indigenous Peoples and their use of critical care services, as a strategic priority, may aid in the development of initiatives for improving health equity. A global focus was selected to learn from Indigenous populations’ experiences with critical care, as the understanding of critical illness among Indigenous Peoples in Canada is not well understood. This protocol outlines a systematic review focused on describing the incidence of critical illness and utilization of critical care services among Indigenous Peoples. Methods Ovid MEDLINE/PubMed, Ovid EMBASE, Google Scholar, and Cochrane Central Register of Controlled Trials will be searched. Relevant Canadian sites for gray literature (National Collaborating Centre for Indigenous Health, First Nations Health Authority, Canadian Institutes of Health Research Institute of Indigenous Peoples’ Health, National Association of Friendship Centres, the Alberta First Nations Information Governance Centre, Métis Nation of Alberta) will also be searched. We will include studies of adults (≥18 years) either without critical illness (i.e., general population) or with critical illness (i.e., admitted to an intensive care unit (ICU)). The exposure of interest will be Indigenous identity. Primary outcome measures are ICU admission and ICU mortality. Because heterogeneity in populations, comparisons, and outcome measures is anticipated, it is likely that the findings will be summarized using a narrative synthesis. A meta-analysis will be performed if there is sufficient evidence on one or more outcomes of interest. Discussion This systematic review will provide a better understanding of the epidemiology, risk factors, and outcomes of critical illness and utilization of critical care services among Indigenous Peoples. The knowledge generated will be applied to a broader program of work designed to create ethical space to co-design, implement, and evaluate a culturally competent, safe, and innovative model for critical care services for Indigenous People. Systematic review registration PROSPERO CRD42021254661

Background Patients being discharged from the intensive care unit (ICU) have variable risks of subsequent readmission or death; however, there is limited understanding of how to predict individual patient risk. We sought to derive risk prediction models for ICU readmission or death after ICU discharge to guide clinician decision-making. Methods Systematic review and meta-analysis to identify risk factors. Development and validation of risk prediction models using two retrospective cohorts of patients discharged alive from medical-surgical ICUs (n = 3 ICUs, n = 11,291 patients; n = 14 ICUs, n = 11,400 patients). Models were developed using literature and data-derived weighted coefficients. Results Sixteen variables identified from the systematic review were used to develop four risk prediction models. In the validation cohort there were 795 (7%) patients who were re-admitted to ICU and 703 (7%) patients who died after ICU discharge. The area under the curve (AUROC) for ICU readmission for the literature (0.615 [95%CI: 0.593, 0.637]) and data (0.652 [95%CI: 0.631, 0.674]) weighted models showed poor discrimination. The AUROC for death after ICU discharge for the literature (0.708 [95%CI: 0.687, 0.728]) and local data weighted (0.752 [95%CI: 0.733, 0.770]) models showed good discrimination. The negative predictive values for ICU readmission and death after ICU discharge ranged from 94%-98%. Conclusions Identifying risk factors and weighting coefficients using systematic review and meta-analysis to develop prediction models is feasible and can identify patients at low risk of ICU readmission or death after ICU discharge.

Purpose Transitions of care from the intensive care unit (ICU) to a hospital ward are high risk and contingent on effective communication. We sought to identify essential information elements to be included in an ICU to hospital ward transfer summary tool, and describe tool functionality and composition perceived to be important. Materials and methods A panel of 13 clinicians representing ICU and hospital ward providers used a modified Delphi process to iteratively review and rate unique information elements identified from existing ICU transfer tools through three rounds of review (two remote and one in person). Qualitative content analysis was conducted on transcribed audio recordings of the workshop to characterize tool functionality and composition. Results A total of 141 unique information elements were reviewed of which 63 were identified by panelists as essential. Qualitative content analyses of panelist discussions identified three themes related to how information elements should be considered when developing an ICU transfer summary tool: 1) Flexibility, 2) Usability, and 3) Accountability. Conclusion We identified 63 distinct information elements identified as essential for inclusion in an ICU transfer summary tool to facilitate communication between providers during the transition of patient care from the ICU to a hospital ward.

BACKGROUND: The transfer of critically ill patients from the intensive care unit (ICU) to hospital ward is challenging. Shortcomings in the delivery of care for patients transferred from the ICU have been associated with higher healthcare costs and poor satisfaction with care. Little is known about how hospital ward providers, who accept care of these patients, perceive current transfer practices nor which aspects of transfer they perceive as needing improvement. OBJECTIVE: To compare ICU and ward administrator perspectives regarding ICU-to-ward transfer practices and evaluate the content of transfer tools. DESIGN: Cross-sectional survey design. PARTICIPANTS: We administered a survey to 128 medical and/or surgical ICU and 256 ward administrators to obtain institutional perspectives on ICU transfer practices. We performed qualitative content analysis on ICU transfer tools received from respondents. KEY RESULTS: In total, 108 (77%) ICU and 160 (63%) ward administrators responded to the survey. The ICU attending physician was reported to be “primarily responsible” for the safety (93% vs. 91%; p = 0.515) of patient transfers. ICU administrators more commonly perceived discharge summaries to be routinely included in patient transfers than ward administrators (81% vs. 60%; p = 0.006). Both groups identified information provided to patients/families, patient/family participation during transfer, and ICU-ward collaboration as opportunities for improvement. A minority of hospitals used ICU-to-ward transfer tools (11%) of which most (n = 21 unique) were designed to communicate patient information between providers (71%) and comprised six categories of information: demographics, patient clinical course, corrective aids, mobility at discharge, review of systems, and documentation of transfer procedures. CONCLUSION: ICU and ward administrators have similar perspectives of transfer practices and identified patient/family engagement and communication as priorities for improvement. Key information categories exist. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-018-4590-8) contains supplementary material, which is available to authorized users.

BACKGROUND: Transfer of patient care from an intensive care unit (ICU) to a hospital ward is often challenging, high risk and inefficient. We assessed patient and provider perspectives on barriers and facilitators to high-quality transfers and recommendations to improve the transfer process. METHODS: We conducted semistructured interviews of participants from a multicentre prospective cohort study of ICU transfers conducted at 10 hospitals across Canada. We purposively sampled 1 patient, 1 family member of a patient, 1 ICU provider, and 1 ward provider at each of the 8 English-speaking sites. Qualitative content analysis was used to derive themes, subthemes and recommendations. RESULTS: The 35 participants described 3 interrelated, overarching themes perceived as barriers or facilitators to high-quality patient transfers: resource availability, communication and institutional culture. Common recommendations suggested to improve ICU transfers included implementing standardized communication tools that streamline provider–provider and provider–patient communication, using multimodal communication to facilitate timely, accurate, durable and mutually reinforcing information transfer; and developing procedures to manage delays in transfer to ensure continuity of care for patients in the ICU waiting for a hospital ward bed. INTERPRETATION: Patient and provider perspectives attribute breakdown of ICU-to-ward transfers of care to resource availability, communication and institutional culture. Patients and providers recommend standardized, multimodal communication and transfer procedures to improve quality of care.

Objective To enable the valid and reliable measurement of patient experiences we previously published a multicenter multi-center validation of the Quality of Trauma Care Patient-Reported Experience Measure (QTAC-PREM). The purpose of this study was to derive a simplified, short form version of the QTAC-PREM to further enhance the feasibility of measuring patient experiences in injury care. To identify candidate items for the short form we reviewed the results of the original multi-center long form validation cohort study, which included 400 injury care patients and their family members recruited from three trauma centers. We only included the best performing items on the revised short form. Results The acute care component of the measure was shortened by 30% and the post-acute care component was shortened by 42%. We identified two subscales on the acute measure (information and communication; clinical and ancillary care) and one subscale on the post-acute measure (post-discharge information and communication). The measurement properties of the short form measure were similar to that of the validated long form. This short form assessment of patient injury care experiences offers a useful, practical, and easy tool for trauma centers to implement for service evaluation, quality improvement, and injury care research. Electronic supplementary material The online version of this article (10.1186/s13104-017-3031-9) contains supplementary material, which is available to authorized users.

Participation in exercise programs postmyocardial infarction is highly protective against future events and mortality. Unfortunately, uptake and maintenance of exercise participation has been documented as being low. This is thought to be due to a myriad of barriers. Qualitative research is a powerful tool to explain behaviors. We sought to summarize existing qualitative literature exploring patient perspectives of participation in exercise after a cardiac event. We updated and built upon a previous systematic review and meta-synthesis by identifying qualitative literature that was not previously captured. We used grounded formal theory to synthesize the qualitative findings in the selected literature. This process led to the development of a comprehensive conceptual framework for understanding the determinants of exercise participation. We found that external, internal, and cultural factors work together as umbrella themes to influence exercise initiation and continued participation in patients who have experienced a cardiac event. Internal factors expand into physical, cognitive, and emotional domains, which include fear, motivation, and mood. External factors include the domains of pragmatic and social considerations such as safety, accessibility, and social support networks. Cognitive and social domains were the most frequently cited factors influencing participation in exercise programs. The framework we outline allows for a more complete understanding of the factors that influence the exercise behaviors of patients with coronary artery disease. Cardiac rehabilitation programs should consider the key factors and capitalize on this knowledge, making these facilitators rather than barriers to exercise participation.

The aim of this study was to develop and evaluate the content validity of quality criteria for providing patient- and family-centered injury care.Quality criteria have been developed for clinical injury care, but not patient- and family-centered injury care.Using a modified Research AND Development Corporation (RAND)/University of California, Los Angeles (UCLA) Appropriateness Methodology, a panel of 16 patients, family members, injury and quality of care experts serially rated and revised criteria for patient- and family-centered injury care identified from patient and family focus groups. The criteria were then sent to 384 verified trauma centers in the United States, Canada, Australia, and New Zealand for evaluation.A total of 46 criteria were rated and revised by the panel over 4 rounds of review producing 14 criteria related to clinical care (n = 4; transitions of care, pain management, patient safety, provider competence), communication (n = 3; information for patients/families; communication of discharge plans to patients/families, communication between hospital and community providers), holistic care (n = 4; patient hygiene, kindness and respect, family access to patient, social and spiritual support) and end-of-life care (n = 3; decision making, end-of-life care, family follow-up). Medical directors, managers, or coordinators representing 254 trauma centers (66% response rate) rated 12 criteria to be important (95% of responses) for patient- and family-centered injury care. Fewer centers rated family access to the patient (80%) and family follow-up after patient death (65%) to be important criteria.Fourteen-candidate quality criteria for patient- and family-centered injury care were developed and shown to have content validity. These may be used to guide quality improvement practices.

Background Systematic reviews of non-randomized controlled trials (RCTs) suggest that using a checklist results in fewer medical errors and adverse events, but these evaluations are at risk of bias. Objective To conduct a systematic review of RCTs of checklists to determine their effectiveness in improving patient safety outcomes in hospitalized patients. Methods Ovid EMBASE, Ovid MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials were searched from inception until December 8, 2016. The search was restricted to RCTs. Included studies reported patient safety outcomes of a checklist intervention. Data extracted included the study characteristics, setting, population, intervention, outcomes measures, and sample size. Measurements and main results 11,225 citations were identified, of which 9 (16,987 patients) satisfied the inclusion criteria. Citations reported evaluations of checklists designed to improve surgical safety, prescription of medications, heart failure management, pain control, infection control precautions, and physician handover. Studies reported significant reductions in postoperative complications and medication-related problems and improved compliance with evidence-based prescribing of medications, infection control precautions, and patient handover procedures. 30-day mortality was reported in 3 studies and was significantly lower among patients allocated to the checklist group (odds ratio 0.60, 95% confidence interval, 0.41-0.89, 𝑃 = 0.01, I² = 0.0%, 𝑃 = 0.573). Methodological quality of the studies was moderate. Conclusion A small number of citations report RCT evaluations of the impact of checklists on patient safety. There is an urgent need for high-quality evaluations of the effectiveness of patient safety checklists in inpatient healthcare settings to substantiate their perceived benefits.

KEY POINTS Despite universal access to publicly funded physician and hospital care, wide disparities in health outcomes exist among communities across Alberta.[1][1] For instance, the age-standardized prevalence rate of diabetes is roughly 4.5 to 16.1 per 100 000 people across Alberta communities.[2

Background With healthcare striving to shift to a more person-centered delivery model, patient and family involvement must have a bigger role in shaping this. While many initiatives involving patients and family members focus on self-care, a broader understanding of patient participation is necessary. Ensuring a viable and sustainable critical number of qualified patients and family members to support this shift will be of utmost importance. The purpose of this study was to understand how health systems are intentionally investing in the training and skill development of patients and family members. Methods Patient co-investigators and researchers conducted a scoping review of the existing literature on methods adopted by healthcare systems to build the skills and capacity of patients to participate in healthcare decision-making using a recognized methodological framework. Six electronic databases were searched to identify studies. Two independent reviewers screened titles and abstracts and full-text papers for inclusion. The research team independently extracted data. Any disagreements were resolved by achieving consensus through discussion. Quantitative and qualitative content synthesis, as well as a quality assessment, was conducted. Results After eliminating duplicates, the search resulted in 9428 abstracts. Four hundred fifty-eight articles were reviewed and 15 articles were included. Four themes emerged: forums (33%), patient instructors (20%), workshops (33%), and co-design (13%). Four of the identified studies measured the impact and overall effectiveness of the respective programs. Examples of how patient and family members were supported (invested in) included advocacy training to support future involvement in engagement activities, a training program to conduct patient-led research, involvement in an immersive experience-based co-design initiative, and involvement in training pharmacy students. Overall, these studies found positive outcomes when patients and family members were recipients of these opportunities. Conclusions The results of this scoping review demonstrate that an evidence base around programs to advance patient engagement is largely absent. An opportunity exists for further research to identify strategies and measures to support patient engagement in healthcare decision-making. Electronic supplementary material The online version of this article (10.1186/s13643-019-0994-8) contains supplementary material, which is available to authorized users.

BACKGROUND We conducted a scoping review to systematically review the literature reporting patient discharge from ICUs, identify facilitators and barriers to high-quality care, and describe tools developed to improve care. METHODS We searched Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials. Data were extracted on the article type, study details for research articles, patient population, phase of care during discharge, and dimensions of health-care quality. RESULTS From 8, 154 unique publications we included 224 articles. Of these, 131 articles (58%) were original research, predominantly case series (23%) and cohort (16%) studies; 12% were narrative reviews; and 11% were guidelines/policies. Common themes included patient and family needs/experiences (29% of articles) and the importance of complete and accurate information (26%). Facilitators of high-quality care included provider-patient communication (30%), provider-provider communication (25%), and the use of guidelines/policies (29%). Patient and family anxiety (21%) and limited availability of ICU and ward resources (26%) were reported barriers to high-quality care. A total of 47 tools to facilitate patient discharge from the ICU were identified and focused on patient evaluation for discharge (29%), discharge planning and teaching (47%), and optimized discharge summaries (23%). CONCLUSIONS Common themes, facilitators and barriers related to patient and family needs/experiences, communication, and the use of guidelines/policies to standardize patient discharge from ICU transcend the literature. Candidate tools to improve care are available; comparative evaluation is needed prior to broad implementation and could be tested through local quality-improvement programs.

Background Providers have traditionally established priorities for quality improvement; however, patients and their family members have recently become involved in priority setting. Little is known about how to reconcile priorities of different stakeholder groups into a single prioritized list that is actionable for organizations. Objective To describe the decision-making process for establishing consensus used by a diverse panel of stakeholders to reconcile two sets of quality improvement priorities (provider/decision maker priorities n=9; patient/family priorities n=19) into a single prioritized list. Design We employed a modified Delphi process with a diverse group of panellists to reconcile priorities for improving care of critically ill patients in the intensive care unit (ICU). Proceedings were audio-recorded, transcribed and analysed using qualitative content analysis to explore the decision-making process for establishing consensus. Setting and participants Nine panellists including three providers, three decision makers and three family members of previously critically ill patients. Results Panellists rated and revised 28 priorities over three rounds of review and reached consensus on the “Top 5” priorities for quality improvement: transition of patient care from ICU to hospital ward; family presence and effective communication; delirium screening and management; early mobilization; and transition of patient care between ICU providers. Four themes were identified as important for establishing consensus: storytelling (sharing personal experiences), amalgamating priorities (negotiating priority scope), considering evaluation criteria and having a priority champion. Conclusions Our study demonstrates the feasibility of incorporating families of patients into a multistakeholder prioritization exercise. The approach described can be used to guide consensus building and reconcile priorities of diverse stakeholder groups.

Background Improving care is a key strategy for reducing the burden of injuries, but it is unknown whether the use of quality indicators (QI) is associated with patient outcomes. We sought to evaluate the association between the use of QIs by trauma centers and outcomes in adult injury patients. Methods We identified consecutive adult patients (n = 223,015) admitted to 233 verified trauma centers January 1, 2007 to December 31, 2010 that contributed data to the National Trauma Data Bank and participated in a survey of QI practices. Generalized Linear Mixed Models were employed to evaluate the association between the intensity (number of QIs) and nature (report cards, internal and external benchmarking) of QI use and survival to hospital discharge, adjusting for patient and hospital characteristics. Results There were no significant differences in the odds of survival to trauma center discharge according to the number of QIs measured (quartiles; odds ratio{OR} [95% confidence interval{CI}] 1.00 vs. 1.08 [0.90–1.31] vs. 1.00 [0.82–1.22] vs. 1.21 [0.99–1.49]), or whether centers used reports cards (OR 1.07, 95%CI 0.94–1.23), internal (OR 1.06, 95%CI 0.89–1.26) or external (OR 1.09, 95%CI 0.92–1.31) benchmarking. The duration (geometric mean) of mechanical ventilation (4.0 days), ICU stay (4.6 days), hospital stay (7.7 days) and proportion of patients with a complication (13.6%) did not significantly differ according to the intensity or nature of QI use. Conclusions The intensity and nature of the QIs used by trauma centers was not associated with outcomes of patient care. Alternative quality improvement strategies may be needed.

OBJECTIVE: To provide the first description of intensive care unit (ICU) discharge practices from the perspective of Canadian ICU administrators, and ICU providers from Canada, the United States and the United Kingdom.METHODS: The authors identified 140 Canadian ICUs and administered a survey to ICU administrators (unit manager, director) to obtain an institutional perspective. Also surveyed were members of professional critical care associations in Canada, the United States and the United Kingdom, using membership distribution lists, to obtain a provider perspective.RESULTS: A total of 118 ICU administrators (114 ICUs [81%]) and 737 ICU providers (denominator unknown) responded to the survey. Administrator and provider respondents reported that ICU physicians are primarily responsible for determining the timing (70% and 77%, respectively) and safety (94% and 96%) for patients discharged from ICU. The majority of respondents indicated that patient summaries (87% and 85%) and medication reconciliation (78% and 79%) were part of their institutions’ discharge process. One-half of respondents reported the use of discharge protocols, while a minority indicated that checklists (46% and 44%), electronic tools (19% and 28%) or outreach follow-up (44% and 33%) were used. The majority of respondents rated current ICU discharge practices to be of medium quality (57% and 58% scored 3 on a five-point scale). Suggested opportunities for improvement included the information provided to patients and families (71% and 59%) and collaboration among hospital units (65% and 66%).CONCLUSION: Findings from the present study revealed the complexity of the ICU discharge process, considerable practice variation, perception of only medium quality and several proposed opportunities for improvement.

We conducted a scoping review to systematically review the literature reporting patient discharge from ICUs, identify facilitators and barriers to high-quality care, and describe tools developed to improve care.We searched Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials. Data were extracted on the article type, study details for research articles, patient population, phase of care during discharge, and dimensions of health-care quality.From 8,154 unique publications we included 224 articles. Of these, 131 articles (58%) were original research, predominantly case series (23%) and cohort (16%) studies; 12% were narrative reviews; and 11% were guidelines/policies. Common themes included patient and family needs/experiences (29% of articles) and the importance of complete and accurate information (26%). Facilitators of high-quality care included provider-patient communication (30%), provider-provider communication (25%), and the use of guidelines/policies (29%). Patient and family anxiety (21%) and limited availability of ICU and ward resources (26%) were reported barriers to high-quality care. A total of 47 tools to facilitate patient discharge from the ICU were identified and focused on patient evaluation for discharge (29%), discharge planning and teaching (47%), and optimized discharge summaries (23%).Common themes, facilitators and barriers related to patient and family needs/experiences, communication, and the use of guidelines/policies to standardize patient discharge from ICU transcend the literature. Candidate tools to improve care are available; comparative evaluation is needed prior to broad implementation and could be tested through local quality-improvement programs.