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Article ; Online: Does pain optimisation impact delirium outcomes in critically ill patients? A systematic review and meta-analysis protocol.

Leong, Amanda Y / Burry, Lisa / Fiest, Kirsten M / Doig, Christopher J / Niven, Daniel J

2024 Volume 14, Issue 1, Page(s) e078395

Abstract: Background: Untreated pain is associated with short-term and long-term consequences, including post-traumatic stress disorder and insomnia. Side effects of some analgesic medications include dysphoria, hallucinations and delirium. Therefore, both ... ...

Abstract	Background: Untreated pain is associated with short-term and long-term consequences, including post-traumatic stress disorder and insomnia. Side effects of some analgesic medications include dysphoria, hallucinations and delirium. Therefore, both untreated pain and analgesic medications may be risk factors for delirium. Delirium is associated with longer length of stay or cognitive impairment. Our systematic review and meta-analysis will examine the relationship between pain or analgesic medications with delirium occurrence, duration and severity among critically ill adults. Methods and analysis: MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of controlled trials and a review of recent conference abstracts will be searched without restriction from inception to 15 May 2023. Study inclusion criteria are: (1) age≥18 years admitted to intensive care; (2) report a measure of pain, analgesic medications and delirium; (3) study design-randomised controlled trial, quasiexperimental designs and observational cohort and case-control studies excluding case reports. Study exclusion criteria are: (1) alcohol withdrawal delirium or delirium tremens; or (2) general anaesthetic emergence delirium; or (3) lab or animal studies. Risk of bias will be assessed with the Risk of Bias V.2 and risk of bias in non-randomised studies tools. There is no language restriction. Occurrence estimates will be transformed using the Freeman-Tukey double arcsine. Point estimates will be pooled using Hartung-Knapp Sidik-Jonkman random effects meta-analysis to estimate a pooled risk ratio. Statistical heterogeneity will be estimated with the I Ethics and dissemination: Ethical approval is not required as this is an analysis of published aggregated data. We will share our findings at conferences and in peer-reviewed journals. Prospero registration number: The finalised protocol was submitted to the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42022367715).
MeSH term(s)	Adult ; Animals ; Humans ; Adolescent ; Alcoholism ; Critical Illness ; Substance Withdrawal Syndrome ; Systematic Reviews as Topic ; Meta-Analysis as Topic ; Pain ; Emergence Delirium ; Analgesics ; Review Literature as Topic
Chemical Substances	Analgesics
Language	English
Publishing date	2024-01-22
Publishing country	England
Document type	Randomized Controlled Trial ; Journal Article
ZDB-ID	2599832-8
ISSN	2044-6055 ; 2044-6055
ISSN (online)	2044-6055
ISSN	2044-6055
DOI	10.1136/bmjopen-2023-078395
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Article ; Online: Context, Culture, and the Complexity of De-Implementing Low-Value Care Comment on "Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands".

Sypes, Emma E / Leigh, Jeanna Parsons / Stelfox, Henry T / Niven, Daniel J

International journal of health policy and management

2022 Volume 11, Issue 8, Page(s) 1592–1594

Abstract: Low-value care contributes to poor quality of care and wasteful spending in healthcare systems. In Verkerk and colleagues' recent qualitative study, interviews with low-value care experts from Canada, the United States, and the Netherlands identified a ... ...

Abstract	Low-value care contributes to poor quality of care and wasteful spending in healthcare systems. In Verkerk and colleagues' recent qualitative study, interviews with low-value care experts from Canada, the United States, and the Netherlands identified a broad range of nationally relevant social, system, and knowledge factors that promote ongoing use of low-value care. These factors highlight the complexity of the problem that is persistent use of low-value care and how it is heavily influenced by public and medical culture as well as healthcare system features. This commentary discusses how these findings integrate within current low-value care and de-implementation literature and uses specific low-value care examples to highlight the importance of considering context, culture, and clinical setting when considering how to apply these factors to future de-implementation initiatives.
MeSH term(s)	United States ; Humans ; Netherlands ; Low-Value Care ; Delivery of Health Care ; Canada
Language	English
Publishing date	2022-02-09
Publishing country	Iran
Document type	Journal Article ; Comment
ZDB-ID	2724317-5
ISSN	2322-5939 ; 2322-5939
ISSN (online)	2322-5939
ISSN	2322-5939
DOI	10.34172/ijhpm.2022.6968
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Article: Predicting Abnormal Laboratory Blood Test Results in the Intensive Care Unit Using Novel Features Based on Information Theory and Historical Conditional Probability: Observational Study.

Valderrama, Camilo E / Niven, Daniel J / Stelfox, Henry T / Lee, Joon

JMIR medical informatics

2022 Volume 10, Issue 6, Page(s) e35250

Abstract: Background: Redundancy in laboratory blood tests is common in intensive care units (ICUs), affecting patients' health and increasing health care expenses. Medical communities have made recommendations to order laboratory tests more judiciously. Wise ... ...

Abstract	Background: Redundancy in laboratory blood tests is common in intensive care units (ICUs), affecting patients' health and increasing health care expenses. Medical communities have made recommendations to order laboratory tests more judiciously. Wise selection can rely on modern data-driven approaches that have been shown to help identify low-yield laboratory blood tests in ICUs. However, although conditional entropy and conditional probability distribution have shown the potential to measure the uncertainty of yielding an abnormal test, no previous studies have adapted these techniques to include them in machine learning models for predicting abnormal laboratory test results. Objective: This study aimed to address the limitations of previous reports by adapting conditional entropy and conditional probability to extract features for predicting abnormal laboratory blood test results. Methods: We used an ICU data set collected across Alberta, Canada, which included 55,689 ICU admissions from 48,672 patients. We investigated the features of conditional entropy and conditional probability by comparing the performances of 2 machine learning approaches for predicting normal and abnormal results for 18 blood laboratory tests. Approach 1 used patients' vitals, age, sex, and admission diagnosis as features. Approach 2 used the same features plus the new conditional entropy-based and conditional probability-based features. Both approaches used 4 different machine learning models (fuzzy model, logistic regression, random forest, and gradient boosting trees) and 10 metrics (sensitivity, specificity, accuracy, precision, negative predictive value [NPV], F Results: Approach 1 achieved an average AUC of 0.86 for all 18 laboratory tests across the 4 models (sensitivity 78%, specificity 84%, precision 82%, NPV 75%, F Conclusions: The findings suggest that conditional entropy-based features and pretest probability improve the capacity to discriminate between normal and abnormal laboratory test results. Detecting the next laboratory test result is an intermediate step toward developing guidelines for reducing overtesting in the ICU.
Language	English
Publishing date	2022-06-03
Publishing country	Canada
Document type	Journal Article
ZDB-ID	2798261-0
ISSN	2291-9694
ISSN	2291-9694
DOI	10.2196/35250
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Article ; Online: The Normal Abnormal Vital Sign of Sepsis.

Laupland, Kevin B / Niven, Daniel J

Critical care medicine

2017 Volume 45, Issue 4, Page(s) 747–748

MeSH term(s)	Emergency Service, Hospital ; Humans ; Intensive Care Units ; Sepsis ; Shock, Septic ; Vital Signs
Language	English
Publishing date	2017-05-01
Publishing country	United States
Document type	Editorial ; Comment
ZDB-ID	197890-1
ISSN	1530-0293 ; 0090-3493
ISSN (online)	1530-0293
ISSN	0090-3493
DOI	10.1097/CCM.0000000000002303
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Article ; Online: Designing a Behaviour Change Wheel guided implementation strategy for a hypoxaemic respiratory failure and ARDS care pathway that targets barriers.

Parhar, Ken Kuljit S / Knight, Gwen E / Soo, Andrea / Bagshaw, Sean M / Zuege, Danny J / Niven, Daniel J / Fiest, Kirsten M / Stelfox, Henry T

BMJ open quality

2023 Volume 12, Issue 4

Abstract: Background: A significant gap exists between ideal evidence-based practice and real-world application of evidence-informed therapies for patients with hypoxaemic respiratory failure (HRF) and acute respiratory distress syndrome (ARDS). Pathways can ... ...

Abstract	Background: A significant gap exists between ideal evidence-based practice and real-world application of evidence-informed therapies for patients with hypoxaemic respiratory failure (HRF) and acute respiratory distress syndrome (ARDS). Pathways can improve the quality of care provided by helping integrate and organise the use of evidence informed practices, but barriers exist that can influence their adoption and successful implementation. We sought to identify barriers to the implementation of a best practice care pathway for HRF and ARDS and design an implementation science-based strategy targeting these barriers that is tailored to the critical care setting. Methods: The intervention assessed was a previously described multidisciplinary, evidence-based, stakeholder-informed, integrated care pathway for HRF and ARDS. A survey questionnaire (12 open text questions) was administered to intensive care unit (ICU) clinicians (physicians, nurses, respiratory therapists) in 17 adult ICUs across Alberta. The Behaviour Change Wheel, capability, opportunity, motivation - behaviour components, and Theoretical Domains Framework (TDF) were used to perform qualitative analysis on open text responses to identify barriers to the use of the pathway. Behaviour change technique (BCT) taxonomy, and Affordability, Practicality, Effectiveness and cost-effectiveness, Acceptability, Side effects and safety and Equity (APEASE) criteria were used to design an implementation science-based strategy specific to the critical care context. Results: Survey responses (692) resulted in 16 belief statements and 9 themes with 9 relevant TDF domains. Differences in responses between clinician professional group and hospital setting were common. Based on intervention functions linked to each belief statement and its relevant TDF domain, 26 candidate BCTs were identified and evaluated using APEASE criteria. 23 BCTs were selected and grouped to form 8 key components of a final strategy: Audit and feedback, education, training, clinical decision support, site champions, reminders, implementation support and empowerment. The final strategy was described using the template for intervention description and replication framework. Conclusions: Barriers to a best practice care pathway were identified and were amenable to the design of an implementation science-based mitigation strategy. Future work will evaluate the ability of this strategy to improve quality of care by assessing clinician behaviour change via better adherence to evidence-based care.
MeSH term(s)	Adult ; Humans ; Critical Pathways ; Motivation ; Behavior Therapy ; Physicians ; Respiratory Insufficiency
Language	English
Publishing date	2023-12-30
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ISSN	2399-6641
ISSN (online)	2399-6641
DOI	10.1136/bmjoq-2023-002461
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Article ; Online: Facilitators and Barriers Influencing Antipsychotic Medication Prescribing and Deprescribing Practices in Critically Ill Adult Patients: a Qualitative Study.

Jaworska, Natalia / Krewulak, Karla D / Schalm, Emma / Niven, Daniel J / Ismail, Zahinoor / Burry, Lisa D / Leigh, Jeanna Parsons / Fiest, Kirsten M

Journal of general internal medicine

2023 Volume 38, Issue 10, Page(s) 2262–2271

Abstract: Background: Antipsychotic medications do not alter the incidence or duration of delirium, but these medications are frequently prescribed and continued at transitions of care in critically ill patients when they may no longer be necessary or appropriate. ...

Abstract	Background: Antipsychotic medications do not alter the incidence or duration of delirium, but these medications are frequently prescribed and continued at transitions of care in critically ill patients when they may no longer be necessary or appropriate. Objective: The purpose of this study was to identify and describe relevant domains and constructs that influence antipsychotic medication prescribing and deprescribing practices among physicians, nurses, and pharmacists that care for critically ill adult patients during and following critical illness. Design: We conducted qualitative semi-structured interviews with critical care and ward healthcare professionals including physicians, nurses, and pharmacists to understand antipsychotic prescribing and deprescribing practices for critically ill adult patients during and following critical illness. Participants: Twenty-one interviews were conducted with 11 physicians, five nurses, and five pharmacists from predominantly academic centres in Alberta, Canada, between July 6 and October 29, 2021. Main measures: We used deductive thematic analysis using the Theoretical Domains Framework (TDF) to identify and describe constructs within relevant domains. Key results: Seven TDF domains were identified as relevant from the analysis: Social/Professional role and identity; Beliefs about capabilities; Reinforcement; Motivations and goals; Memory, attention, and decision processes; Environmental context and resources; and Beliefs about consequences. Participants reported antipsychotic prescribing for multiple indications beyond delirium and agitation including patient and staff safety, sleep management, and environmental factors such as staff availability and workload. Participants identified potential antipsychotic deprescribing strategies to reduce ongoing antipsychotic medication prescriptions for critically ill patients including direct communication tools between prescribers at transitions of care. Conclusions: Critical care and ward healthcare professionals report several factors influencing established antipsychotic medication prescribing practices. These factors aim to maintain patient and staff safety to facilitate the provision of care to patients with delirium and agitation limiting adherence to current guideline recommendations.
MeSH term(s)	Humans ; Adult ; Antipsychotic Agents/therapeutic use ; Critical Illness/therapy ; Deprescriptions ; Qualitative Research ; Delirium/drug therapy ; Alberta/epidemiology
Chemical Substances	Antipsychotic Agents
Language	English
Publishing date	2023-04-18
Publishing country	United States
Document type	Journal Article
ZDB-ID	639008-0
ISSN	1525-1497 ; 0884-8734
ISSN (online)	1525-1497
ISSN	0884-8734
DOI	10.1007/s11606-023-08042-5
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Article ; Online: De-implementing low value care in critically ill patients: a call for action-less is more.

Stelfox, Henry T / Bourgault, Annette M / Niven, Daniel J

Intensive care medicine

2019 Volume 45, Issue 10, Page(s) 1443–1446

MeSH term(s)	Critical Care/methods ; Critical Care/standards ; Critical Care/trends ; Critical Illness/therapy ; Evidence-Based Practice/methods ; Evidence-Based Practice/trends ; Humans ; Medical Overuse/prevention & control ; Quality of Health Care/standards
Language	English
Publishing date	2019-08-08
Publishing country	United States
Document type	Journal Article
ZDB-ID	80387-x
ISSN	1432-1238 ; 0340-0964 ; 0342-4642 ; 0935-1701
ISSN (online)	1432-1238
ISSN	0340-0964 ; 0342-4642 ; 0935-1701
DOI	10.1007/s00134-019-05694-y
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Article ; Online: Association of Premorbid Blood Pressure with Vasopressor Infusion Duration in Patients with Shock.

Gershengorn, Hayley B / Stelfox, Henry T / Niven, Daniel J / Wunsch, Hannah

American journal of respiratory and critical care medicine

2020 Volume 202, Issue 1, Page(s) 91–99

Abstract: Rationale: ...

Abstract	Rationale:
MeSH term(s)	Adolescent ; Adult ; Aged ; Aged, 80 and over ; Alberta ; Blood Pressure/drug effects ; Female ; Humans ; Hypertension/complications ; Hypertension/physiopathology ; Hypotension/complications ; Hypotension/physiopathology ; Length of Stay/statistics & numerical data ; Logistic Models ; Male ; Middle Aged ; Multivariate Analysis ; Practice Guidelines as Topic ; Practice Patterns, Physicians'/statistics & numerical data ; Retrospective Studies ; Shock/complications ; Shock/drug therapy ; Shock/mortality ; Shock/physiopathology ; Treatment Outcome ; Vasoconstrictor Agents/administration & dosage ; Vasoconstrictor Agents/pharmacology ; Vasoconstrictor Agents/therapeutic use ; Young Adult
Chemical Substances	Vasoconstrictor Agents
Language	English
Publishing date	2020-04-09
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	1180953-x
ISSN	1535-4970 ; 0003-0805 ; 1073-449X
ISSN (online)	1535-4970
ISSN	0003-0805 ; 1073-449X
DOI	10.1164/rccm.201908-1681OC
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Article ; Online: STOP Signs: A Population-based Interrupted Time Series Analysis of Antibiotic Duration for Complicated Intraabdominal Infection Before and After the Publication of a Landmark RCT.

Ng-Kamstra, Joshua S / Soo, Andrea / McBeth, Paul / Rotstein, Ori / Zuege, Danny J / Gregson, Daniel / Doig, Christopher James / Stelfox, Henry T / Niven, Daniel J

Annals of surgery

2023 Volume 277, Issue 5, Page(s) e984–e991

Abstract: Objective: To determine if the STOP-IT randomized controlled trial changed antibiotic prescribing in patients with Complicated Intraabdominal Infection (CIAI).: Summary of background data: CIAI is common and causes significant morbidity. In May 2015, ...

Abstract	Objective: To determine if the STOP-IT randomized controlled trial changed antibiotic prescribing in patients with Complicated Intraabdominal Infection (CIAI). Summary of background data: CIAI is common and causes significant morbidity. In May 2015, the STOP-IT randomized controlled trial showed equivalent outcomes between four-day and clinically determined antibiotic duration. Methods: This was a population-based retrospective cohort study using interrupted time series methods. The STOP-IT publication date was the exposure. Median duration of inpatient antibiotic prescription was the outcome. All adult patients admitted to four hospitals in Calgary, Canada between July 2012 and December 2018 with CIAI who survived at least four days following source control were included. Analysis was stratified by infectious source as appendix or biliary tract (group A) versus other (group B). Results: Among 4384 included patients, clinical and demographic attributes were similar before vs after publication. In Group A, median inpatient antibiotic duration was 3 days and unchanged from the beginning to the end of the study period [adjusted median difference -0.00 days, 95% confidence interval (CI) -0.37 - 0.37 days]. In Group B, antibiotic duration was shorter at the end of the study period (7.87 vs 6.73 days; -1.14 days, CI-2.37 - 0.09 days), however there was no change in trend following publication (-0.03 days, CI -0.16 - 0.09). Conclusions: For appendiceal or biliary sources of CIAI, antibiotic duration was commensurate with the experimental arm of STOP-IT. For other sources, antibiotic duration was long and did not change in response to trial publication. Additional implementation science is needed to improve antibiotic stewardship.
MeSH term(s)	Adult ; Humans ; Anti-Bacterial Agents/therapeutic use ; Hospitalization ; Interrupted Time Series Analysis ; Intraabdominal Infections/drug therapy ; Intraabdominal Infections/chemically induced ; Retrospective Studies ; Randomized Controlled Trials as Topic
Chemical Substances	Anti-Bacterial Agents
Language	English
Publishing date	2023-04-06
Publishing country	United States
Document type	Journal Article
ZDB-ID	340-2
ISSN	1528-1140 ; 0003-4932
ISSN (online)	1528-1140
ISSN	0003-4932
DOI	10.1097/SLA.0000000000005231
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Article ; Online: Multicentre implementation of a quality improvement initiative to reduce delirium in adult intensive care units: An interrupted time series analysis.

Owen, Victoria S / Sinnadurai, Selvi / Morrissey, Jeanna / Colaco, Heather / Wickson, Patty / Dyjur, Donalda / Redlich, Melissa / O'Neill, Barbara / Zygun, David A / Doig, Christopher J / Harris, Jo / Zuege, Danny J / Stelfox, Henry T / Faris, Peter D / Fiest, Kirsten M / Niven, Daniel J

Journal of critical care

2024 Volume 81, Page(s) 154524

Abstract: Purpose: The ABCDEF bundle may improve delirium outcomes among intensive care unit (ICU) patients, however population-based studies are lacking. In this study we evaluated effects of a quality improvement initiative based on the ABCDEF bundle in adult ... ...

Abstract	Purpose: The ABCDEF bundle may improve delirium outcomes among intensive care unit (ICU) patients, however population-based studies are lacking. In this study we evaluated effects of a quality improvement initiative based on the ABCDEF bundle in adult ICUs in Alberta, Canada. Material and methods: We conducted a pre-post, registry-based clinical trial, analysed using interrupted time series methodology. Outcomes were examined via segmented linear regression using mixed effects models. The main data source was a population-based electronic health record. Results: 44,405 consecutive admissions (38,400 unique patients) admitted to 15 general medical/surgical and/or neurologic adult ICUs between 2014 and 2019 were included. The proportion of delirium days per ICU increased from 30.24% to 35.31% during the pre-intervention period. After intervention implementation it decreased significantly (bimonthly decrease of 0.34%, 95%CI 0.18-0.50%, p < 0.01) from 33.48% (95%CI 29.64-37.31%) in 2017 to 28.74% (95%CI 25.22-32.26%) in 2019. The proportion of sedation days using midazolam demonstrated an immediate decrease of 7.58% (95%CI 4.00-11.16%). There were no significant changes in duration of invasive ventilation, proportion of partial coma days, ICU mortality, or potential adverse events. Conclusions: An ABCDEF delirium initiative was implemented on a population-basis within adult ICUs and was successful at reducing the prevalence of delirium.
MeSH term(s)	Adult ; Humans ; Alberta/epidemiology ; Critical Care ; Delirium/epidemiology ; Delirium/prevention & control ; Intensive Care Units ; Interrupted Time Series Analysis ; Quality Improvement
Language	English
Publishing date	2024-01-10
Publishing country	United States
Document type	Clinical Trial ; Journal Article ; Multicenter Study
ZDB-ID	632818-0
ISSN	1557-8615 ; 0883-9441
ISSN (online)	1557-8615
ISSN	0883-9441
DOI	10.1016/j.jcrc.2024.154524
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