Browsing by Author "Stelfox, H. Thomas"

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    Assessment of Intensive Care Unit Outreach Transition Programs effect on readmissions and mortality among ICU survivors discharged to ward in Calgary – a Time Series Study.
    (2017) Freitas Bastos, Jaime; Stelfox, H. Thomas; Bagshaw, Sean; Chowdhury, Tanvir T.; Quinn, Robert
    Introduction: Potentially preventable errors and adverse events can occur as a consequence of patient transfer of care between health care providers. Intensive Care Unit transition programs (ICUTP) are a type of Rapid Response System Model, which presents a very simple idea: if a patient shows signs of imminent clinical deterioration, a team of providers is called up to the bedside to immediately assess and treat the patient in order to prevent intensive care unit transfer, cardiac arrest, or death. ICUTP incorporate ICU transition assignments, having a role in facilitating discharge and providing a smooth transition for complex convalescent patients to a general hospital ward. However, when assessing the ICU transition assignments for these teams, there is a substantial lack of available data, essential for assessing their effectiveness. This led us to inquire into the real role of a program in which significant investments have been placed. Objectives: Primary: To assess if ICU transition programs decrease the risk of ICU readmission when compared to standard care among patients who survive their initial admission to an adult ICU. Secondary: To assess if ICU transition programs decrease the risk of in-hospital mortality when compared to standard care among patients who survive their initial admission to an adult ICU. Methods: We performed an interrupted time series (ITS) study, a variation of time-series studies classified as quasi-experiments, involving all adults older than 18 years old, who survived their first ICU admission and were discharged to ward between 2002 and 2010 in Calgary, Alberta. The outcomes (ICU readmission and hospital mortality) were measured at every 3 months, before and after the implementation of our ICUTP - the ICU outreach team (ICUOT). Multivariable segmented logistic regression was used to adjust the estimates of the odds ratio (OR) of each outcome measure before and after the intervention. Data were reported as odds ratios (OR) and proportions with 95% confidence intervals (CI) and were evaluated for multicollinearity and autocorrelation. Results: At the start of the study 6.0% (95% confidence interval [CI] 4.9% to 7.0%) of the patients of our study population were readmitted to ICU. During the pre-intervention period, we could see a non-significant decrease of 0.02%(-0.02%, 95% CI -0.10% to +0.07%) in the proportion of patients readmitted to ICU per quarter of study. After implementation of the ICUOT, there was a 2.0% significant increase in the proportion of patients readmitted to ICU (+2.0%, 95% CI +0.5% to +3.2%). Subsequently, we saw a non-significant decrease in that proportion (-0.04% per quarter; 95% CI, -0.2% to +0.1%). At the end of the study, the proportion of patients readmitted in the ICU was 6.0% (95% CI, 4.8% to 7.0%). Regarding hospital mortality, 7.0% (95% confidence interval [CI] 6.0% to 9.0%) of the patients of our study population died in the hospital at the start of the study period. In the pre-intervention period, there was a non-significant decrease of 0.01% (-0.01% 95% CI, -0.09% to +0.07%) in the proportion of patients who died in the hospital per quarter. After implementation of the ICUOT, there was an immediate non-significant increase of 1.0% in the proportion of patients dying in the hospital, (+1.0%, 95% CI -0.3% to +2.4%). Subsequently, there was a significant small decrease in that proportion (-0.2% per quarter; 95% CI, -0.3% to -0.05%). At the end of the study, the proportion of in-hospital deaths was 4.0% (95% CI, 3.0% to 5.0%). Conclusion: This work, based on a robust methodology that uses an interrupted time series with segmented logistic regression, showed that ICU readmission rates remain the same based on the estimated changes in intercept and slope when comparing pre and post-intervention periods. There is insufficient evidence of a statistically significant effect of the ICUOT on ICU readmissions. However, it is possible that closer monitoring and faster actions on those ICU survivors who required or did not required ICU readmission have been lead to a small but significant improvement in mortality.
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    Assessment of the safety and feasibility of administering anti-pyretic therapy in critically ill adults: a randomized clinical trial
    (2012) Niven, Daniel J.; Laupland, K. B.; Stelfox, H. Thomas
    There is a paucity of evidence to guide the management of febrile, critically ill patients without acute brain injury. This pilot, randomized clinical trial assessed the safety and feasibility of administering two different fever control strategies in critically ill adults. The biologic response to fever control was also assessed through analysis of several inflammatory mediators. Of the 179 patients screened for enrolment, 14 were randomized to the aggressive treatment group and 12 to the permissive group. The most common reason for exclusion from the trial was the presence of liver disease (22.2%). There were no significant differences in any of the markers of safety, and the fever control strategies did not appreciably influence the biology of fever. The most notable finding was a reduced number of patients with fever compared to that expected (31 % ). This impacted study participant recruitment and will affect the feasibility of completing a larger phase III study.
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    Developing a patient and family-centred approach for measuring the quality of injury care: a study protocol
    (BioMed Central, 2013-01-27) Stelfox, H. Thomas; Boyd, Jamie M.; Straus, Sharon E.; Gagliardi, Anna R.
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    Intensivists' base specialty of training is associated with variations in mortality and practice patterns
    (BioMed Central, 2009-12-29) Billington, Emma O.; Zygun, David A; Stelfox, H. Thomas; Peets, Adam D.
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    Late Life Search Strategy
    (2016-11) Fiest, Kirsten; Job McIntosh, Christiane; Stelfox, H. Thomas; Parsons Leigh, Jeanna
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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.