How Emergency Medicine Residents Have Conversations About Life-Sustaining Treatments in Critical Illness: A Qualitative Study Using Inductive Thematic Analysis.

Study Objective: The inherent pressures of high-acuity, critical illness in the emergency department create a unique environment whereby acute goals-of-care discussions must be had with patients or substitute decision makers to rapidly decide between divergent treatment paths. Among university-affiliated hospitals, resident physicians are often conducting these highly consequential discussions. This study aimed to use qualitative methods to explore how emergency medicine residents make recommendations regarding life-sustaining treatments during acute goals-of-care discussions in critical illness.

Impact of baseline beta-blocker use on inotrope response and clinical outcomes in cardiogenic shock: a subgroup analysis of the DOREMI trial.

Background: Cardiogenic shock (CS) is associated with significant morbidity and mortality. The impact of beta-blocker (BB) use on patients who develop CS remains unknown. We sought to evaluate the clinical outcomes and hemodynamic response profiles in patients treated with BB in the 24 h prior to the development of CS.

Cost of Futile ICU Care in One Ontario Hospital.

Critical care is a costly and finite resource that provides the ability to manage patients with life-threatening illnesses in the most advanced forms available. However, not every condition benefits from critical care. There are unrecoverable health states in which it should not be used to perpetuate.

Survey on Barriers to Critical Care and Palliative Care Integration.

Purpose: It has been shown that integrating palliative care (PC) in intensive care unit (ICU) improves end-of-life care (EOLC), but very few Canadian hospitals have adopted this practice. Our study aims to evaluate the perceived quality of EOLC at participating institutions and explore barriers toward ICU-PC integration.

Materials And Methods: A self-administered questionnaire was developed by a multidisciplinary team.

An Analysis of Pay-for-Performance Schemes and Their Potential Impacts on Health Systems and Outcomes for Patients.

Pay-for-performance (P4P) programs have been introduced into the Canadian medical system in the last decades. This paper examines the underlying characteristics of P4P and describes both their advantages and drawbacks. Most P4P programs provide the advantage of rewarding medical acts, thus providing an incentive to take on complex patients.

Outcomes and Cost of Patients With Terminal Cancer Admitted to Acute Care in the Final 2 Weeks of Life: A Retrospective Chart Review.

Background: Patients with terminal conditions are often admitted to the emergency department (ED) for acute medical services, but studies have suggested that multiple ED admissions may negatively impact end-of-life (EOL) care. Research have shown that incorporating palliative care (PC) is integral to optimal EOL care, but it is an aspect of medical practice that is often neglected. The current study sought to provide an overview of health outcomes and hospital costs of patients with cancer admitted to The Ottawa Hospital and/or received acute medical services during their final 2 weeks of life.

Ethical failings of CPSO policy and the health care consent act: case review.

End-of-life disputes in Ontario are currently overwhelmingly assessed through the singular lens of patient autonomy. The current dispute resolution mechanism(s) does not adequately consider evidence-based medical guidelines, standards of care, the patient's best interests, expert opinion, or distributive justice. We discuss two cases adjudicated by the Consent and Capacity board of Ontario that demonstrate the over emphasis on patient autonomy.

Defibrillator Design and Usability May Be Impeding Timely Defibrillation.

Background: Timely defibrillation is the only rhythm-specific therapy proven to increase survival to hospital discharge following cardiac arrest secondary to ventricular tachyarrhythmia. Delayed defibrillation occurs in more than 30% of this population. A study was conducted to test the hypothesis that unintuitive defibrillator design and lack of usability are barriers to timely defibrillation, as measured by time to defibrillation and the proportion of defibrillations delivered within 2 minutes.

The impact of reducing intensive care unit length of stay on hospital costs: evidence from a tertiary care hospital in Canada.

Purpose: To use theoretical modelling exercises to determine the effect of reduced intensive care unit (ICU) length of stay (LOS) on total hospital costs at a Canadian centre.

Methods: We conducted a retrospective cost analysis from the perspective of one tertiary teaching hospital in Canada. Cost, demographic, clinical, and LOS data were retrieved through case-costing, patient registry, and hospital abstract systems of The Ottawa Hospital Data Warehouse for all new in-patient ward (30,483) and ICU (2,239) encounters between April 2012 and March 2013.

Critical care at the end of life: a population-level cohort study of cost and outcomes.

Background: Despite the high cost associated with ICU use at the end of life, very little is known at a population level about the characteristics of users and their end of life experience. In this study, our goal was to characterize decedents who received intensive care near the end of life and examine their overall health care use prior to death.

Methods: This was a retrospective cohort study that examined all deaths in a 3-year period from April 2010 to March 2013 in Ontario, Canada.

Cost analysis of the very elderly admitted to intensive care units.

Background: Very elderly patients are often admitted to intensive care units (ICUs) despite poor outcomes and frequent preference to avoid unnecessary prolongation of life. We sought to determine the cost of ICU admission for the very elderly and the factors influencing this cost.

Methods: This prospective, observational cohort study included patients ≥80 years old admitted to 22 Canadian ICUs from 2009 to 2013.

Neuroscience Intermediate-Level Care Units Staffed by Intensivists: Clinical Outcomes and Cost Analysis.

Introduction:: With an aging population and increasing numbers of intensive care unit admissions, novel ways of providing quality care at reduced cost are required. Closed neurointensive care units improve outcomes for patients with critical neurological conditions, including decreased mortality and length of stay (LOS). Small studies have demonstrated the safety of intermediate-level units for selected patient populations.

Approach to economic analysis in critical care.

There are 4 general economic analyses used in health care: cost minimization, cost-benefit, cost-effectiveness, and cost utility. In this review, we provide an overview of each of these analyses and examine their appropriateness and effectiveness in assessing critical care costs. In the intensive care unit setting, it is particularly important to consider the patients' quality of life following the treatment of critical illness and to adopt a societal perspective when conducting economic analyses.

Compartment Syndrome as a Result of Systemic Capillary Leak Syndrome.

Objective. To describe a single case of Systemic Capillary Leak Syndrome (SCLS) with a rare complication of compartment syndrome. Patient.

The Impact of Palliative Care Consultation in the ICU on Length of Stay: A Systematic Review and Cost Evaluation.

Introduction: The intensive care unit (ICU) consumes 20% of hospital expenditures and 1% of gross domestic product. Many strategies have been attempted to reduce ICU costs. A systematic review was conducted to evaluate the effect of palliative care (PC) consultations in the ICU on length of stay (LOS) and costs.

Effectiveness of an extended period of flashing lights and strategic signage to increase the salience of alcohol-gel dispensers for improving hand hygiene compliance.

Background: Multiple factors affect compliance with hand hygiene, including conspicuity of alcohol-gel dispensers. Previous studies have shown that flashing lights increase hand hygiene compliance; however, the durability of this effect has not been studied.

Methods: We affixed flashing lights to hand sanitizer dispensers for a total of 6 weeks.

A study of the efficacy of flashing lights to increase the salience of alcohol-gel dispensers for improving hand hygiene compliance.

Background: Many interventions have been implemented to improve hand hygiene compliance, each with varying effects and monetary costs. Although some previous studies have addressed the issue of conspicuousness, we found only 1 study that considered improving hand hygiene by using flashing lights.

Method: Our attention theory-based hypothesis tested whether a simple red light flashing at 2-3 Hz affixed to the alcohol gel dispensers, within the main hospital entrance, would increase hand hygiene compliance over the baseline rate.

Increasing benefit from revascularization is associated with increasing amounts of myocardial hibernation: a substudy of the PARR-2 trial.

Objectives: We sought to determine: 1) whether F-18-fluorodeoxyglucose (FDG) positron emission tomography (PET) parameters identify high-risk patients who gain benefit from revascularization; 2) whether there is a cut point for such benefit; and 3) predictors of outcome in patients with severe left ventricular (LV) dysfunction due to coronary artery disease.

Background: Patients with ischemic LV dysfunction might benefit from revascularization but not without risk. The FDG PET imaging can detect viable myocardium that recovers after revascularization.

Pneumocystis jiroveci pneumonia prophylaxis is not required with a CD4+ T-cell count < 200 cells/microl when viral replication is suppressed.

Objective: To determine the safety of discontinuing Pneumocystis jiroveci pneumonia (PCP) prophylaxis, in patients on effective antiretroviral therapy with CD4+ T-cell counts that have plateaued at < 200 cells/microl.

Methods: We prospectively evaluated a cohort of HIV infected patients at a multidisciplinary HIV clinic with sustained HIV RNA levels < 50 copies/ml and CD4+ T-cell counts that have plateaued at < 200 cells/microl and who have discontinued PCP prophylaxis.

Results: Nineteen patients fulfilled the above criteria.

Granulocyte-macrophage colony-stimulating factor (GM-CSF) and inflammatory stimuli up-regulate secretion of the soluble GM-CSF receptor in human monocytes: evidence for ectodomain shedding of the cell surface GM-CSF receptor alpha subunit.

Soluble GM-CSF receptor alpha subunit (sGMRalpha) is a soluble isoform of the GMRalpha that is believed to arise exclusively through alternative splicing of the GMRalpha gene product. The sGMRalpha mRNA is expressed in a variety of tissues, but it is not clear which cells are capable of secreting the protein. We show here that normal human monocytes, but not lymphocytes, constitutively secrete sGMRalpha.