Browsing by Author "Gilfoyle, Elaine"

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    An Exploration of Deference Behaviours Exhibited within the Paediatric Resuscitation Environment
    (2017) Delaloye, Nicole; Gilfoyle, Elaine; Oddone Paolucci, Elizabeth; Ellaway, Rachel; Kassam, Aliya
    Healthcare professionals’ deference to physician expertise has been observed across a variety of clinical settings. Although such behaviour often results in appropriate and efficient patient care, deference can become detrimental when an inappropriate order or action goes unchallenged. This study aimed to identify the underlying factors influencing deference behaviours exhibited within the paediatric resuscitation environment. Through a three-phase study design and thematic analysis approach informed by principles of grounded theory, six overarching factors were found to influence deference behaviours: factors located outside the resuscitation environment, factors located inside the resuscitation environment, individual characteristics, mental state and experience, cognition, and motivation. Together these six factors were found to influence deference and its associated actions and responses (obedience, conformity, compromise, and rejection). The identification of these factors and this novel understanding of deference could potentially guide healthcare professionals, educators, and researchers in the development of strategies to mitigate instances of compromised patient care.x
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    Developing an Antimicrobial Stewardship Education Curriculum Framework
    (2021-03-03) Constantinescu, Cora Mihaela; Kassam, Aliya; Conly, John M.; Vayalumkal, Joseph Varkey; Gilfoyle, Elaine
    Background: Antimicrobial Stewardship (AS) education initiatives often neglect to account for the psychosocial factors driving antimicrobial prescribing (AP). Understanding these key factors is important in the design and implementation of tailored educational initiatives. Methods: This study which applied a mixed-methods embedded design, involved quantitative analysis of AS concerns observed by pharmacists through a clinical team rounds audit, as well as qualitative semi-structured interviews based on the Theoretical Domain Framework (TDF). Interviews (n=23) with staff and resident physicians, nurse practitioners and pharmacists were conducted for the Clinical Teaching Unit (CTU) and Pediatric Intensive Care Unit (PICU). We analyzed the data using deductive and inductive methods by mapping nodes from the TDF to a model for social determinants of antimicrobial prescribing (SDAP) in pediatrics. Facilitators and barriers to AP behaviour were identified and represented with respect to Kern’s Model of curriculum development targeted at future PICU and CTU AS education initiatives. Results: The quantitative phase served as an educational needs assessment, identifying chief AS practice (e.g., de-escalation) and antibiotics concerns. The qualitative phase explored AP behaviours and identified psychosocial facilitators and barriers for AS practice. Some facilitators included: 1. Collaboration and trust, 2. Shared decision-making with pharmacy and the Infectious Disease (ID) service, 3. Local accessible guidelines and 4. Overarching goals such as: doing right by the patient and feeling empowered as a prescriber. Some barriers included: 1. The norm of non-interference, 2. Professional comparisons including issues with hierarchy and egos, 3. Limited resources, 4. Feeling inadequately trained in AS, 5. Emotional prescribing in the face of clinical deterioration and diagnostic uncertainty and 6. Pejorative monitoring system. A conceptual framework was then developed using these facilitators and barriers for future educational initiatives for inpatient teams. Conclusions: This study contributes to the gap of knowledge around how best to optimize AS education for multidisciplinary teams. This is the first study in pediatrics taking into consideration the psychosocial drivers of AP behaviour in the context of team decisions around patient-centred clinical rounds. Mapping these facilitators and barriers to an established educational framework, allows for tailored curriculum development of future AS interventions.
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    Erratum to: Pediatric intensive care stress ulcer prevention (PIC-UP): a protocol for a pilot randomized trial
    (2017-08-18) Duffett, Mark; Choong, Karen; Foster, Jennifer; Gilfoyle, Elaine; Lacroix, Jacques; Pai, Nikhil; Thabane, Lehana; Cook, Deborah J
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    Pediatric intensive care stress ulcer prevention (PIC-UP): a protocol for a pilot randomized trial
    (2017-05-19) Duffett, Mark; Choong, Karen; Foster, Jennifer; Gilfoyle, Elaine; Lacroix, Jacques; Pai, Nikhil; Thabane, Lehana; Cook, Deborah J
    Abstract Background Despite sparse pediatric data on effectiveness, the majority of critically ill children receive medications to prevent gastrointestinal (GI) bleeding. Stress ulcer prophylaxis may have unintended consequences—increasing the risk of nosocomial infections—which may be more serious and common than the bleeding which these drugs are prescribed to prevent. Randomized controlled trials (RCTs) in pediatric critical care are exceptionally challenging to complete, thus a rigorous pilot RCT is crucial. The objective of this pilot RCT is to assess the feasibility of a large multicentre RCT of stress ulcer prophylaxis with pantoprazole to prevent upper GI bleeding vs. placebo. Methods A multi-centre blinded pilot RCT of 120 children in six Canadian PICUs. Children expected to require mechanical ventilation for more than 48 h will be randomized to receive intravenous pantoprazole 1 mg/kg or identical placebo once daily until they no longer need mechanical ventilation. We have four feasibility outcomes and will consider the trial successful if we achieve: 1. Effective screening: If >80% of eligible patients are approached for consent. 2. Timely enrollment: if >80% of participants receive their first dose of the assigned study drug within 1 day of becoming eligible. 3. Participant accrual: If the average monthly enrolment is two or more participants per centre per month. 4. Protocol adherence: if >90% of doses are administered according to the protocol. Discussion There are many uncertainties about the risks and benefits of stress ulcer prophylaxis. In an era of widespread use—where clinicians prescribe prophylaxis to the more severely ill—a large, rigorous RCT is required. A trial to determine if a strategy of withholding stress ulcer prophylaxis is not inferior to a strategy of routine stress ulcer prophylaxis will be challenging. A carefully designed and implemented pilot trial is essential. Trial registration ClinicalTrials.gov: NCT02929563 (Registered October 3, 2016).
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    Rapid normalization of vitamin D deficiency in PICU (VITdALIZE-KIDS): study protocol for a phase III, multicenter randomized controlled trial
    (2024-09-19) O’Hearn, Katie; Menon, Kusum; Albrecht, Lisa; Amrein, Karin; Britz-McKibbin, Philip; Cayouette, Florence; Choong, Karen; Foster, Jennifer R.; Fergusson, Dean A.; Floh, Alejandro; Fontela, Patricia; Geier, Pavel; Gilfoyle, Elaine; Guerra, Gonzalo G.; Gunz, Anna; Helmeczi, Erick; Khamessan, Ali; Joffe, Ari R.; Lee, Laurie; McIntyre, Lauralyn; Murthy, Srinivas; Parsons, Simon J.; Ramsay, Tim; Ryerson, Lindsay; Tucci, Marisa; McNally, Dayre
    Abstract Background The rate of vitamin D deficiency (VDD) in critically ill children worldwide has been estimated at 50%. These children are at risk of multiple organ dysfunction, chronic morbidity, and decreased health related quality of life (HRQL). Pediatric and adult ICU clinical trials suggest that VDD is associated with worse clinical outcomes, although data from supplementation trials are limited and inconclusive. Our group’s phase II multicenter dose evaluation pilot study established the efficacy and safety of an enteral weight-based cholecalciferol loading dose to rapidly restore vitamin D levels in critically ill children. Methods Our aim is to evaluate the impact of this dosing regimen on clinical outcomes. VITdALIZE-KIDS is a pragmatic, phase III, multicenter, double-blind RCT aiming to randomize 766 critically ill children from Canadian PICUs. Participants are randomized using a 1:1 scheme to receive a single dose at enrollment of enteral cholecalciferol (10,000 IU/kg, max 400,000 IU) or placebo. Eligibility criteria include critically ill children aged newborn (> 37 weeks corrected gestational age) to < 18 years who have blood total 25-hydroxyvitamin D < 50 nmol/L. The primary objective is to determine if rapid normalization of vitamin D status improves HRQL at 28 days following enrollment. The secondary objective is to evaluate the impact of rapid normalization of vitamin D status on multiple organ dysfunction. The study includes additional tertiary outcomes including functional status, HRQL and mortality at hospital discharge and 90 days, PICU and hospital length of stay, and adverse events related to vitamin D toxicity. Additionally, we are performing comprehensive vitamin D speciation and non-targeted metabolite profiling as part of a sub-study for the first 100 participants from whom an enrollment and at least one post-intervention blood and urine sample were obtained. Discussion The VITdALIZE-KIDS trial is the first phase III, multicenter trial to evaluate whether rapid normalization of vitamin D status could represent a simple, inexpensive, and safe means of improving outcomes following pediatric critical illness. Recruitment was initiated in June 2019 and is expected to continue to March 2026. Trial registration Clinicaltrials.gov, NCT03742505. Study first submitted on November 12, 2018 https://clinicaltrials.gov/study/NCT03742505
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    Reducing the impact of intensive care unit mattress compressibility during CPR: a simulation-based study
    (2017-11-16) Lin, Yiqun; Wan, Brandi; Belanger, Claudia; Hecker, Kent; Gilfoyle, Elaine; Davidson, Jennifer; Cheng, Adam
    Abstract Background The depth of chest compression (CC) during cardiac arrest is associated with patient survival and good neurological outcomes. Previous studies showed that mattress compression can alter the amount of CCs given with adequate depth. We aim to quantify the amount of mattress compressibility on two types of ICU mattresses and explore the effect of memory foam mattress use and a backboard on mattress compression depth and effect of feedback source on effective compression depth. Methods The study utilizes a cross-sectional self-control study design. Participants working in the pediatric intensive care unit (PICU) performed 1 min of CC on a manikin in each of the following four conditions: (i) typical ICU mattress; (ii) typical ICU mattress with a CPR backboard; (iii) memory foam ICU mattress; and (iv) memory foam ICU mattress with a CPR backboard, using two different sources of real-time feedback: (a) external accelerometer sensor device measuring total compression depth and (b) internal light sensor measuring effective compression depth only. CPR quality was concurrently measured by these two devices. The differences of the two measures (mattress compression depth) were summarized and compared using multilevel linear regression models. Effective compression depths with different sources of feedback were compared with a multilevel linear regression model. Results The mean mattress compression depth varied from 24.6 to 47.7 mm, with percentage of depletion from 31.2 to 47.5%. Both use of memory foam mattress (mean difference, MD 11.7 mm, 95%CI 4.8–18.5 mm) and use of backboard (MD 11.6 mm, 95% CI 9.0–14.3 mm) significantly minimized the mattress compressibility. Use of internal light sensor as source of feedback improved effective CC depth by 7–14 mm, compared with external accelerometer sensor. Conclusion Use of a memory foam mattress and CPR backboard minimizes mattress compressibility, but depletion of compression depth is still substantial. A feedback device measuring sternum-to-spine displacement can significantly improve effective compression depth on a mattress. Trial registration Not applicable. This is a mannequin-based simulation research.
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    Team Adaptation in High Reliability Teams
    (2020-06-17) Deacon, Amanda; O'Neill, Thomas A.; Gilfoyle, Elaine; Caird, Jeffrey K.; MacInnis, Cara C.; Cheng, Adam; Grossman, Rebecca
    This research attempts to identify key components of adaptation in high reliability teams, with the goal being error reduction. The current literature is limited in its lack of empirical evidence showing how these models may differ based upon specific characteristics of high reliability teams. This topic is explored through three separate studies using resuscitation teams faced with family presence as a representation of a high reliability team requiring adaptation. Our first study sought to cultivate deeper understanding of the trigger and how it may potentially affect a team via a scoping study of family presence. The second study used qualitative analysis of debriefs with the sample population to identify key processes of successful team adaptation. In our third study, we used a mixed methods approach to test and provide evidence for the existence of the key processes and states identified in the second study. How this evidence contributes to our understanding of team adaptation in high reliability teams is discussed in the final chapter. Our findings indicate that high reliability teams differ from the standard team during the adaptation process and this may impact how we should approach training these teams.
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    The Effect of Hemoglobin Levels on Mortality in Pediatric Patients with Severe Traumatic Brain Injury
    (2016-06-28) Yee, Kevin F.; Walker, Andrew M.; Gilfoyle, Elaine
    Objective. There is increasing evidence of adverse outcomes associated with blood transfusions for adult traumatic brain injury patients. However, current evidence suggests that pediatric traumatic brain injury patients may respond to blood transfusions differently on a vascular level. This study examined the influence of blood transfusions and anemia on the outcome of pediatric traumatic brain injury patients. Design. A retrospective cohort analysis of severe pediatric traumatic brain injury (TBI) patients was undertaken to investigate the association between blood transfusions and anemia on patient outcomes. Measurements and Main Results. One hundred and twenty patients with severe traumatic brain injury were identified and included in the analysis. The median Glasgow Coma Scale (GCS) was 6 and the mean hemoglobin (Hgb) on admission was 115.8 g/L. Forty-three percent of patients (43%) received at least one blood transfusion and the mean hemoglobin before transfusion was 80.1 g/L. Multivariable regression analysis revealed that anemia and the administration of packed red blood cells were not associated with adverse outcomes. Factors that were significantly associated with mortality were presence of abusive head trauma, increasing PRISM score, and low GCS after admission. Conclusion. In this single centre retrospective cohort study, there was no association found between anemia, blood transfusions, and hospital mortality in a pediatric traumatic brain injury patient population.