Browsing by Author "Stelfox, Henry Thomas"
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Item Open Access Acute Care Surgery Outcomes(2019-05-15) Al-Busaidi, Omar Mohammed; Kortbeek, John Barry; Ball, Chad Geoffrey G.; Stelfox, Henry Thomas; Austen, Lea; Turin, Tanvir ChowdhuryIntroduction: The acute care surgery (ACS) model was initiated two decades ago to address issues of availability, timeliness and quality in emergency general surgery care. Previous publications were retrospective, single centred and lacked specific information about morbidity and mortality rates of common ACS procedures. Given that ACS is an evolving model and that the full impact of its implementation is not yet fully understood, we studied the effect of ACS implementation on morbidity and mortality. Methods: Part I, a systematic review and meta-analysis of outcome studies of appendectomies and cholecystectomies before and after the implementation of ACS. Part II, a prospective analysis of ACS post-operative morbidities and mortality in 8 high-volume centres (excluding trauma) was performed. The evaluation was conducted over a 30-day period. Results: In part I, of 1704 studies, 27 studies were selected for analysis. Following ACS introduction, the overall complication rate was significantly reduced in both appendectomy and cholecystectomy (Risk ratios = 0.7; 95% CI 0.57 to 0.85 and RR=0.6; 95% CI 0.40 to 0.94) respectively. Length of stay and time to operate were significantly reduced in both groups. In part II, there were a total of 601 post-operative patients who were followed for up to a period of 30 days. Of those, 66% of the procedures were laparoscopic. The overall complication rate was 34% and mortality was 2%. In open procedures, the morbidity rate was 73%. Conclusions: The implementation of the ACS model was associated with a significant reduction in morbidity and mortality in patients’ with appendicitis and cholecystitis. ACS patients continue to represent a high-risk population. Appropriate hospital and system resources are essential for successful implementation of the ACS model. Keywords: Acute care surgery, ACS, appendectomy, cholecystectomy. MorbidityItem Open Access Caring for the Critically Ill(2021-09-21) Moss, Stephana Julia; Bobawsky, Kirsten Marie; Stelfox, Henry Thomas; Doig, Christopher James; Patten, Scott BurtonFamily or informal caregivers are key to the delivery of patient-centered care and often act as patient advocates. Visitation from family caregivers in the intensive care unit (ICU) can have long-term impacts on ICU patients post-hospital discharge. A relationship between exposure to critical illness and negative psychological sequalae among family caregivers of critically ill patients is consistently reported. The literature on mental health interventions to improve psychological outcomes in family caregivers of the critically ill has not been appraised. Bereavement interventions in the ICU have not been mapped to core outcomes for evaluating bereavement support among family caregivers. The effect of family visitation on ICU survivors post-discharge psychiatric outcomes is unknown. Perspectives from designated family caregivers during the coronavirus disease 2019 (COVID-19) pandemic have not been well characterized. The work reported in this thesis addresses these knowledge gaps. Based on a systematic review of 102 trials, mental health interventions reduced anxiety (Ratio of Means (RoM), 0.92; 95% confidence interval (CI): 0.87–0.97) and depression (RoM, 0.83; 95%CI: 0.69–0.99), but not post-traumatic stress disorder (RoM, 0.91; 95%CI: 0.80–1.04) or distress (RoM, 1.01; 95%CI: 0.95–1.07) among family caregivers within 3-months post-discharge. Increased burden among family caregivers within 3-months post-discharge (RoM, 1.08; 95%CI: 1.05–1.12) was observed. Three studies of ICU bereavement interventions indicated that available trial evidence is sparse and does not support use of bereavement interventions for family caregivers of patients who die in ICU. Using administrative databases, it was found that ICU family visitation was associated with decreased risk for psychiatric disorders (risk ratio (RR), 0.87; 95%CI: 0.79-0.97), mainly trauma- and stressor-related disorders (RR 0.66; 95%CI: 0.38-0.87), in ICU survivors up to one-year post-discharge. In COVID-19, designated family caregivers of critically ill patients perceived emotional distress related to being the only family member allowed to visit. The results of these studies characterize the impact of a family-centered care approach in the ICU on caring for the critically ill, which is integrated into recommendations for the field.Item Open Access Clinical manifestations of tension pneumothorax: protocol for a systematic review and meta-analysis(BioMed Central, 2014-01-04) Roberts, Derek J.; Leigh-Smith, Simon; Faris, Peter D.; Ball, Chad G.; Robertson, Helen Lee; Blackmore, Christopher; Dixon, Elijah; Kirkpatrick, Andrew W.; Kortbeek, John B.; Stelfox, Henry ThomasItem Open Access Clinical review: Medication errors in critical care(BioMed Central, 2008-03) Moyen, Eric; Camiré, Eric; Stelfox, Henry ThomasItem Open Access Delirium severity and patient health outcomes: a systematic review and meta-analysis(2018-04-25) Rosgen, Brianna; Krewulak, Karla D.; Ely, E. Wesley; Stelfox, Henry Thomas; Fiest, Kirsten M.Item Open Access Determinants of tracheostomy decannulation: an international survey(BioMed Central, 2008-02) Stelfox, Henry Thomas; Crimi, Claudia; Berra, Lorenzo; Noto, Alberto; Schmidt, Ulrich; Bigatello, Luca M; Hess, DeanItem Open Access Development and Evaluation of Risk Models to Predict Readmission or Death Following Discharge from an Adult General Systems Intensive Care Unit(2018-07-06) Boyd, Jamie; Stelfox, Henry Thomas; James, Matthew T.; Zuege, Danny J.Transitions of care from intensive care unit (ICU) to ward are high-risk periods of healthcare delivery associated with ICU readmission and post-ICU mortality. Evidence-based processes for transitions are crucial for improving outcomes. Validated prediction models that include consistently associated risk factors for ICU readmission or post-ICU mortality may help to improve these practices. This mixed-methods thesis was comprised of three distinct phases: 1) systematic review and meta-analysis; 2) development of prediction models for ICU Readmission and Post-ICU Mortality using two approaches (literature-derived coefficients, data-derived coefficients [Derivation Cohort]), 3) validation of the models in an external Validation Cohort. The models for ICU Readmission showed limited discriminative ability whereas the Post-ICU Mortality models were stronger. Developing prediction models using pooled measures of association is a feasible approach, producing similar results to more the traditional data-derived method. Additional investigation to further validate the findings is required.Item Open Access Development and Validation of the Quality of Trauma Care Patient-Reported Experience Measure(2014-01-29) Bobrovitz, Niklas; Stelfox, Henry ThomasTo deliver patient-centered injury care, patient perspectives must be incorporated into quality measurement and improvement. Therefore, the purpose of this thesis was to develop and validate a measure of patient experience for use as a quality improvement tool in injury care. A draft survey measure of patient injury care experience was revised using cognitive interviews with 30 injury patients/surrogates. A multi-site prospective cohort study of 400 patients/surrogates was conducted and provided evidence of the measure's validity, reliability, and feasibility of implementation. Analysis of responses to the free-text items on the measure indicated that qualitative data obtained from open-ended items may be a valuable supplement to the quantitative component of the measure. The results of this thesis show that the Quality of Trauma Care Patient-Reported Experience Measure (QTAC-PREM) is valid and reliable and could be used as a tool to guide quality improvement efforts.Item Open Access The Development of Patient Safety Indicators for Critically Ill Patients Admitted to the Intensive Care Unit(2020-07-09) Wu, Guosong; Stelfox, Henry Thomas; Wu, Qunhong; Quan, Hude; Ronksley, Paul Everett; Holroyd-Leduc, Jayna M.Patient safety is a top priority in critical care. Patient safety indicators (PSIs) have been developed to measure critical care safety. Despite several approaches have been used to develop PSIs (deductive, inductive, and joint approach), PSIs are widely applied to measure the care performance in Intensive Care Units (ICUs). The overall objective of this thesis was to use a joint approach to develop a PSI that can be used to evaluate the safety of critical care and to assess the reliability and validity of this PSI. Three studies were conducted to achieve this objective. In the first study, we systematically reviewed the literature of PSIs proposed for patients admitted to an ICU. Heterogeneity of PSI definitions were observed. Among 44 unique PSIs identified from 21 studies, reliability and validity of four PSIs was only reported in one study. In the second study, a panel of ICU experts evaluated the 44 unique PSIs identified in our systematic review. The expert panel proposed an additional 20 PSIs and, during a second round, evaluated and prioritized the 64 PSIs using a modified RAND Appropriateness Method. The top ten ranked PSIs included clinically important concepts that had data available in a local electronic database. This included patient falls, which we investigated in our final study. In the third study, we constructed a fall risk predictive model leveraging provincial electronic medical record (EMR) and examined its reliability and validity. Overall, fall incidence rate was 1.55 (95% CI 1.36-1.76) per 1,000 patient days. The model displayed an excellent discrimination (AUC 0.82) and calibration. We propose the definition of Risk-adjusted Standardized Fall Rate (RSFR) to compared critical care performance across sites and overtime in order to test effectiveness of quality improvement strategies. RSFR demonstrates good test re-test reliability (r=0.662) and construct validity (r=0.533). The study proposed PSI for patient falls was developed from a comprehensive systematic review of the literature, structured expert panel review of candidate PSIs, and validated using a local EMR database. The main findings of this thesis support RSFR could be measured and monitored provincially or nationally to benchmark critical care safety performance.Item Open Access The epidemiology of intensive care unit-acquired hyponatraemia and hypernatraemia in medical-surgical intensive care units(BioMed Central, 2008-12-18) Stelfox, Henry Thomas; Ahmed, Sofia B; Khandwala, Farah; Zygun, David; Shahpori, Reza; Laupland, Kevin B.Item Open Access Evaluating the Association Between Delirium in the Intensive Care Unit and Subsequent Neuropsychiatric Disorders Post-Stay(2018-08-03) Brown, Kyla Nicole; Stelfox, Henry Thomas; Fiest, Kirsten; Faris, Peter D.; Patten, Scott BurtonIndividuals without pre-existing neuropsychiatric disorders are reported to be at increased risk of developing a neuropsychiatric disorder after admission to an Intensive Care Unit (ICU). This risk may be attributed to the severity of illness and the nature of therapies provided, including intubation, medically induced coma, and numerous medications. Furthermore, approximately half of ICU patients develop delirium during their stay, which may further add to the burden of neuropsychiatric disorders experienced by these patients. If delirium is not identified and treatment initiated early, patients may be at risk for adverse consequences, such as increased mortality, increased length of hospital stay and further cognitive impairment. Therefore, the objectives of this thesis were to (1) examine the overall prevalence and (2) incidence of neuropsychiatric disorders following a stay in a general systems ICU; and (3) determine the association between delirium in the ICU and an onset of a neuropsychiatric disorders subsequent to the ICU stay. The objectives for this study were addressed in two phases. In phase one, a systematic review and meta-analysis was conducted to address the overall pooled prevalence of depression, anxiety, trauma-and-stressor related, and neurocognitive disorders. Based on the analysis, the overall pooled prevalence of the disorders was: 32% (95% Confidence Interval [CI] 25%-39%), 32% (95% CI 24%-40%), 23% (95% CI 18%- 28%), and 42% (95% CI 25%-60%), respectively. The systematic review revealed a significant association between delirium and neuropsychiatric disorders (specifically trauma-and-stressor related and neurocognitive disorders). In phase two, a retrospective cohort study using administrative databases was conducted. The cumulative incidence for depressive, anxiety, trauma-and-stressor related, and neurocognitive disorders were: 10.6%, 8.9%, 2.5%, and 3.7%, respectively. The study results suggested that for patients who ever had delirium in the ICU, there was a 1.23 times the risk of developing any neuropsychiatric disorder compared to those who never had delirium in the ICU. Early treatment of delirium may be necessary to reduce the morbidity of delirium and possibly the subsequent development of neuropsychiatric disorders post-ICU stay.Item Open Access A Health Technology Reassessment of Red Blood Cell Transfusions in the Intensive Care Unit(2019-08-23) Soril, Lesley Jeanne Josephine; Noseworthy, Tom W.; Clement, Fiona M.; Stelfox, Henry Thomas; Zygun, David A.Health technology reassessment (HTR) is the systematic, evidence-based assessment of the clinical, economic, ethical, and social impacts of an existing health technology to inform its optimal use. A novel model to guide HTR processes has been proposed. The overall aim of this thesis was to test the HTR model in a real-world healthcare context with the technology of red blood cell (RBC) transfusions in the intensive care unit (ICU). This thesis is comprised of 4 studies. The first study was a retrospective observational study of RBC transfusions in 9 Alberta ICUs. Between April 1, 2014 and December 31, 2016, we found that 61% of included RBC transfusions in stable, non-bleeding ICU patients were associated with a pre-transfusion hemoglobin value of 70 g/L or more and cost an estimated $1.82M in healthcare costs. Second, we conducted a systematic review and meta-analyses to determine the effectiveness of interventions on healthcare providers’ RBC transfusion practices. We identified a large and heterogenous body of evidence. Use of any intervention was associated with reduced odds of transfusion, including inappropriate transfusions. However, there was limited understanding of why interventions were selected over others and how this may have affected outcomes. In the third study, we conducted a population-based cross-sectional survey of Alberta ICU physicians to understand their perceptions of RBC transfusions practices using the Theoretical Domains Framework. We identified self-reported facilitators and barriers to practicing a guideline-recommended restrictive RBC transfusion strategy, which could then be mapped to relevant behaviour change interventions to optimize RBC transfusions. Finally, we conducted a controlled before and after pilot study to assess the feasibility of implementing a multi-modal intervention to optimize RBC transfusions in the ICU. The intervention was theory-informed and co-designed with local clinical leaders and included group education and audit and feedback. Early and meaningful stakeholder engagement and tailoring the intervention to interdisciplinary healthcare providers were important for achieving feasibility. Overall, we uncovered critical methodological and practical considerations to advance the emerging field of HTR. With regards to optimizing RBC transfusions, we established the necessary foundation to implement, monitor, and evaluate a larger-scale HTR initiative for ICUs in Alberta.Item Open Access Mapping Current Adult Intensive Care Unit Patient Care Rounding Practices(2015-04-24) Holodinsky, Jessalyn; Stelfox, Henry ThomasEffective communication is essential for high quality patient care; within the ICU the majority of health care provider communication occurs during patient care rounds. While several best practices for rounds have been proposed it is unclear if they are being used in Canadian adult Intensive Care Units (ICU). The objective of this thesis was to describe current rounding practices in a sample of Canadian adult ICUs. A prospective observational study consisting of a national survey and follow up interviews was undertaken. ICU rounding practices were found to be heterogeneous across the country and overall self-rated rounding quality was high, but several opportunities for improvement were highlighted. This thesis proposes five recommendations for rounding practices: defining participants and roles, managing interruptions, further study on patient and family involvement, streamlining teaching during rounds, and creating an objective metric to assess rounding quality. A structured tool for use during ICU rounds is also proposed.Item Open Access Patient, Family Member, and Public Involvement in Identifying Low-Value Clinical Practices for De-adoption: A Mixed Methods Study of Choosing Wisely Initatives(2020-01-31) de Grood, Chloe Moira; Stelfox, Henry Thomas; Parsons-Leigh, Jeanna; Niven, Daniel J.; Clement, Fiona M.Low-value care comprises tests, treatments and procedures where the potential risks outweigh benefits for patients. Despite a growing recognition of the importance to reduce the use of low-value care, ineffective and costly clinical practices continue to be used. While Choosing Wisely and other initiatives have implemented strategies to reduce low-value care, little is known about how to best engage the public in these initiatives. The purpose of this study was to explore the role of patient, family and public members in the development and implementation of Choosing Wisely initiatives that aim to reduce low-value care. A mixed methods study design was used to address the objective through content analysis and qualitative interviews. The content analysis examined two different collections of publicly available online materials (Choosing Wisely clinician lists, i.e., Five Things Physicians and Patients Should Question; and Choosing Wisely patient resources) in order to describe members of the public involvement in Choosing Wisely list creation and development. Content analysis revealed that few members of the public were involved in the development of Choosing Wisely clinician lists. The analysis of patient resource documents suggested that the average Simple Measure of Gobbledygook (SMOG) readability score was a Grade nine level and were categorized at the patient engagement level of Inform where the documents engage the reader by providing only information. Qualitative interviews, conducted to explore future public involvement in reducing low-value care generated five overarching themes: 1) factors influencing understandings of what potentially constitutes low-value care in the clinical interaction; 2) how to communicate about low-value care; 3) perceived barriers to public involvement in the reduction of low-value care (e.g., brief clinical interaction); 4) perceived iii facilitators to public involvement in the reduction of low-value care (e.g., use of educational materials); and 5) suggested strategies to engage the public involvement in Choosing Wisely initiatives. This thesis indicates that there is public involvement in reducing low-value care is feasible and that Choosing Wisely initiatives such as identifying and participating in conversations about low-value care may be an appropriate place for such engagement.Item Open Access The ‘‘To Err is Human’’ report and the patient safety literature(BMJ Publishing Group, 2006-06) Stelfox, Henry Thomas; Palmisani, S.; Scurlock, C.; Orav, E. J.; Bates, D. W.Item Open Access Understanding the Role of the Public in Reducing Low-value Care(2019-06-21) Sypes, Emma Elizabeth; Stelfox, Henry Thomas; Niven, Daniel J.; Parsons-Leigh, Jeanna; Clement, Fiona M.Low-value care consists of medical tests and treatments that are unnecessary, potentially harmful, or not cost-effective and contribute to rising healthcare costs, adverse events, and poor quality of care. In recent years there has been a surge in initiatives aiming to identify and reduce low-value care. However, the role of the public in reducing low-value care remains unclear. The research reported in this thesis aimed to understand the role of the public in reducing low-value care through a systematic and comprehensive review of the literature. A scoping review identified 151 relevant articles. The majority of these articles described or evaluated a strategy for involving the public in reducing low-value care; articles that explored stakeholder perspectives about the role of the public were less common. Public involvement most commonly occurred at the level of the patient-clinician interaction, followed by administrative and policy decision-making and low-value care research. Shared decision-making and patient-oriented education were the most frequent and best supported strategies. There was considerably less support for public involvement at the level of administrative and policy decision-making. A follow-up systematic review and meta-analysis was conducted to estimate the impact of patient-targeted interventions to reduce low-value care. This study found a statistically significant association between patient-targeted interventions (i.e., shared decision-making, patient-oriented education) and a decrease in use of the low-value practices (RR 0.75; 95% CI 0.66-0.84), which remained significant when the meta-analysis was restricted to randomized clinical trials with low risk of bias (RR 0.69; 95% CI 0.58-0.83). Collectively, these two studies show a considerable amount of support for engaging the public in reducing low-value care at the level of the patient-clinician interaction through strategies including shared decision-making and patient-oriented education. There is comparably less evidence to support public involvement in research or administrative and policy decision-making. Additional research to explore stakeholder perspectives and evaluate strategies for public involvement within varying contexts is required to further understand the role of the public in reducing low-value care.