Browsing by Author "Niven, Daniel"

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    Facilitators and barriers to deprescribing antipsychotic medications in critically ill adult patients at transitions of care
    (2022-07-09) Jaworska, Natalia; Fiest, Kirsten; Niven, Daniel; Ismail, Zahinoor
    Antipsychotic medications are prescribed to critically ill adult patients in the intensive care unit (ICU) for clinical indications including delirium, agitation, and sleep disturbances. While there is some evidence for their use in managing agitation, antipsychotic medications have not convincingly shown efficacy for the management of delirium or sleep and are often continued at transitions of care in critically ill patients when they may no longer be necessary or appropriate. The current literature on antipsychotic minimization and deprescribing in critically ill patients is sparse lacking evaluation of underlying facilitators and barriers informing current antipsychotic prescribing practices that may be important in the development of effective minimization and deprescribing strategies. The studies presented in this thesis address knowledge gaps regarding antipsychotic prescribing and deprescribing practices among inpatient healthcare professionals who care for patients with and following critical illness. Based on a qualitative study with semi-structured interviews of 21 healthcare professionals, seven relevant domains from the Theoretical Domains Framework (TDF) contributing to antipsychotic prescribing and deprescribing were identified. A subsequent scoping review of the literature identified differences between healthcare professional perceived and actual prescribing practices, with few in-hospital deprescribing strategies available to guide practice. Thereafter, a nationwide modified Delphi consensus process informed by the qualitative study and scoping review identified consensus statements for antipsychotic minimization activities and antipsychotic deprescribing strategies for patients with and following critical illness. The results of these studies characterize and catalogue relevant priority facilitators and barriers to antipsychotic minimization and deprescribing in critically ill adult patients during their hospitalization to support best clinical prescribing practices.
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    Impact of Family Presence on Delirium in Critically Ill Patients: A Retrospective Cohort Study
    (2021-05-28) Mohsen, Samiha Tarek; Fiest, Kirsten; Sauro, Khara; Niven, Daniel
    Delirium, an acutely disturbed state of consciousness, manifests as a collection of symptoms such as confusion. There is potential for family members of critically ill patients to assist in non-pharmacological delirium prevention and management (e.g., re-orientation). Despite this, there are few studies on the impact of Intensive Care Unit (ICU) family presence on delirium. To bridge these knowledge gaps, our study employed a population-based retrospective cohort design to explore the association between family presence and both the incidence and duration of delirium in critically ill patients. The electronic health records of consecutive adult patients admitted to any of 14 adult medical-surgical adult ICUs in Alberta, Canada between January 1, 2014 and December 30, 2018 were examined. Family presence in the ICU (exposure), was extracted using a validated algorithm (1. family physically present, 2. family phone call only, 3. no family presence or call [reference group]). Delirium was measured using the Intensive Care Delirium Screening Checklist (ICDSC). Incident delirium was quantified (primary outcome) using an ICDSC cut-off of ≥4 points, after family presence (yes/no). Duration of delirium (secondary outcome) was measured as the total number of ICU days (24-hour periods) with a positive ICDSC score (≥4 points). Multivariable mixed-effects logistic and linear regression models (accounting for clustering by patient re-admission and ICU site, where appropriate) were used to evaluate the association between family member presence and the incidence and duration of delirium in critically-ill patients in the ICU, respectively. All regression models were adjusted for relevant covariates (e.g., ICU admission type, Glasgow Coma Scale [GCS]). We included 25,537 patients. Family presence in the ICU was associated with lower incidence of delirium during elective-surgical admissions in patients with intact GCS (OR 0.60, 95%CI:0.39-0.97, p=0.02) as compared to patients in the reference group. Family presence in the ICU decreased duration of delirium (adjusted mean difference -1.87 days, 95%CI: -2.01 to -1.81, p<0.001) as compared to patients in the reference group. Family presence in the ICU may decrease the incidence of delirium in patients admitted for elective-surgical reasons with intact GCS and duration of delirium in all patients by up to 2 days.
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    A Multicentre Implementation of a Quality Improvement Initiative to Reduce Delirium in Adult Intensive Care Units: An Interrupted Time Series Analysis
    (2021-07-27) Owen, Victoria Susan; Niven, Daniel; Fiest, Kirsten; Faris, Peter; Stelfox, Thomas
    In 2016, Alberta Health Services implemented the ICU Delirium Initiative in all intensive care units (ICUs) in Alberta. The ICU Delirium Initiative was based on the ABCDEF care bundle and recommended (A) appropriate pain management, (B) daily breaks in continuous sedation along with lowering mechanical ventilation support, (C) appropriate choices for sedation and pain control, (D) routine screening and management of delirium, (E) early mobilization and (F) engagement of family. The purpose of this thesis was to examine the effects of the ABCDEF delirium care bundle on patient-centred outcomes and processes of care among adults admitted to ICUs in Alberta. An interrupted time series analysis using retrospective linked clinical and administrative data from November 2014 to June 2019 was conducted in 14 adult general medical-surgical and one neurological ICU in Alberta. All patient admissions from each site were included after the site had transitioned to the current population-based electronic health documentation system. Provincial outcome trends were compared before and after the ICU Delirium Initiative was implemented in September 2016. The primary outcome was percent of delirium days per ICU. Secondary outcomes included: ever delirium, duration of mechanical ventilation, percent of coma days per ICU, percentage of sedation days using midazolam, adverse events and ICU length of stay and mortality. All outcomes were examined using mixed effects segmented linear regression with ICU site as the random effect. After the intervention, the overall percent of delirium days per ICU was 33.48% [95% Confidence Interval (CI) 29.64-37.31%] in January/February 2017 and decreased significantly by 0.34% every two months (95% CI 0.18-0.50%) following intervention implementation to a final estimate of 28.74% (95% CI 25.22-32.26%) in May/June 2019. The percentage of sedation days using midazolam decreased immediately following the intervention [decrease of 7.58% (95%CI 4.00-11.16%)]. Additionally, there were no significant changes in major adverse events (e.g., patient fall), minor adverse events (e.g., patient removal of peripheral intravenous), duration of mechanical ventilation, percentage of coma days per ICU or ICU mortality. These results suggest that population-based implementation of the ABCDEF bundle is feasible, effective, and safe.
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    The De-adoption of Low-value Clinical Practices in Adult Critical Care Medicine
    (2015-12-24) Niven, Daniel; Stelfox, H. Thomas; Straus, Sharon; Hemmelgarn, Brenda; Jeffs, Lianne
    Low-value clinical practices are common, and potentially harmful to patients and healthcare systems, yet the optimal approach to reducing (i.e. de-adopting) these practices is unknown. This thesis reports the results of three studies conducted with the overall objective of improving knowledge related to the de-adoption of low-value clinical practices in patients admitted to adult intensive care units (ICUs), an area known to have high resource consumption. First, a scoping review of the literature was conducted to systematically identify current knowledge regarding the science of de-adoption. From 109 citations, this review identified that current terminology is heterogeneous and poorly defined, that most of the literature evaluates the outcomes of some type of de-adoption effort, and that the most common (and least successful) approach to de-adoption is to wait for it to occur following passive diffusion of published research. A framework to guide the de-adoption process is proposed. Second, another scoping review using a replication research framework was conducted to identify low-value clinical practices among patients admitted to adult ICUs. Low-value practices were those wherein new evidence (i.e. replication research) suggests that an intervention previously thought to be beneficial is ineffective or harmful (i.e. evidence reversal). This review demonstrated that the results of nearly half of original replicated citations were reversed (n = 35, 49%), with the highest proportion of reversals in practices originally found to be beneficial (n = 21, 60%). Third, an interrupted time series analysis using the APACHE clinical database and patients admitted to adult ICUs in the United States examined the effects of replication research on clinical practice for a practice with evidence reversal, namely tight glycemic control. This study found notable changes in the practice of glycemic control following a clinical trial that demonstrated the benefits of tight glycemic control, with comparatively less change following a methodologically more rigorous trial that demonstrated its harmful effects. Taken together, the results of these three studies demonstrate the urgent need for additional research to understand and promote the de-adoption of low-value clinical practices.