Activation of a family member refers to their desire, knowledge, confidence, and skills that can inform engagement in healthcare. Family activation combined with opportunity can lead to engagement in ...care. No tool currently exists to measure family activation in acute care. Therefore, we aimed to develop and validate a tool to measure family activation in acute care.
An interdisciplinary team of content experts developed the FAMily Activation Measure (FAM-Activate) through an iterative process. The FAM-Activate tool is a 4-item questionnaire with 5 Likert-type response options (ranging from strongly agree to strongly disagree). Scale scores are converted to a 0-100 point scoring range so that higher FAM-Activate scores indicate increased family activation. An overall FAM-Activate score (range 0-100) is calculated by adding the scores for each item and dividing by 4. We conducted reliability and predictive validity assessments to validate the instrument by administering the FAM-Activate tool to family members of patients in an acute cardiac unit at a tertiary care hospital. We obtained preliminary estimates of family engagement and satisfaction with care.
We surveyed 124 family participants (age 54.1±14.4; 73% women; 34% non-white). Participants were predominantly the adult child (38%) or spouse/partner (36%) of patients. The mean FAM-Activate score during hospitalization was 84.1±16.1. FAM-Activate had acceptable internal consistency (Cronbach's a = 0.74) and showed test-retest responsiveness. FAM-Activate was moderately correlated with engagement behavior (Pearson's correlation r = 0.47, P <0.0001). The FAM-Activate score was an independent predictor of family satisfaction, after adjusting for age, gender, relationship, and living status.
The FAM-Activate tool was reliable and had predictive validity in the acute cardiac population. Further research is needed to explore whether improving family activation can lead to improved family engagement in care.
Purpose
Assessing efficacy of electrical impedance tomography (EIT) in optimizing positive end-expiratory pressure (PEEP) for acute respiratory distress syndrome (ARDS) patients to enhance ...respiratory system mechanics and prevent ventilator-induced lung injury (VILI), compared to traditional methods.
Methods
We carried out a systematic review and meta-analysis, spanning literature from January 2012 to May 2023, sourced from Scopus, PubMed, MEDLINE (Ovid), Cochrane, and LILACS, evaluated EIT-guided PEEP strategies in ARDS versus conventional methods. Thirteen studies (3 randomized, 10 non-randomized) involving 623 ARDS patients were analyzed using random-effects models for primary outcomes (respiratory mechanics and mechanical power) and secondary outcomes (PaO
2
/FiO
2
ratio, mortality, stays in intensive care unit (ICU), ventilator-free days).
Results
EIT-guided PEEP significantly improved lung compliance (
n
= 941 cases, mean difference (MD) = 4.33, 95% confidence interval (CI) 2.94, 5.71), reduced mechanical power (
n
= 148, MD = − 1.99, 95% CI − 3.51, − 0.47), and lowered driving pressure (
n
= 903, MD = − 1.20, 95% CI − 2.33, − 0.07) compared to traditional methods. Sensitivity analysis showed consistent positive effect of EIT-guided PEEP on lung compliance in randomized clinical trials vs. non-randomized studies pooled (MD) = 2.43 (95% CI − 0.39 to 5.26), indicating a trend towards improvement. A reduction in mortality rate (259 patients, relative risk (RR) = 0.64, 95% CI 0.45, 0.91) was associated with modest improvements in compliance and driving pressure in three studies.
Conclusions
EIT facilitates real-time, individualized PEEP adjustments, improving respiratory system mechanics. Integration of EIT as a guiding tool in mechanical ventilation holds potential benefits in preventing ventilator-induced lung injury. Larger-scale studies are essential to validate and optimize EIT’s clinical utility in ARDS management.
Purpose
Macrophage activation syndrome (MAS) is a rare illness, especially in critically ill adults. The diagnosis of MAS is challenging, requiring the expertise of multiple specialists, and ...treatments for MAS can be associated with catastrophic complications.
Clinical features
We describe the case of a 31-yr-old Vietnamese student who was diagnosed with cutaneous systemic lupus erythematosus (SLE) in November 2020 and was initiated on treatment with low-dose corticosteroids and hydroxychloroquine as an outpatient. Ten days later, she presented to hospital with decreased consciousness, fever, periorbital swelling, and hypotension necessitating intubation. Computed tomography angiography (CTA) and lumbar puncture did not show a stroke or central nervous system infection. Serology and clinical presentation were consistent with MAS. She was initially treated with 4.5 g pulse methylprednisolone and subsequently with the interleukin-1 receptor antagonist, anakinra, and maintenance corticosteroids because of persistently elevated inflammatory markers. Her intensive care unit stay was complicated by aspiration, airway obstruction due to fungal tracheobronchitis necessitating extracorporeal membrane oxygenation (ECMO), and ring-enhancing cerebral lesions, and, ultimately, massive hemoptysis resulting in death.
Conclusions
Four features of this case merit discussion, including the: 1) infrequent association of SLE with MAS; 2) short interval between SLE diagnosis and critical illness; 3) manifestation of fungal tracheobronchitis with airway obstruction; and 4) lack of response to antifungal treatment while receiving ECMO.
Only a small proportion of COVID-19 patients in Canada have been recruited into clinical research studies. One reason is that few community intensive care units (ICUs) in Canada participate in ...research. The objective of this study was to examine the motivating factors, barriers and facilitators to research participation amongst Canadian community ICU stakeholders. A cross-sectional online survey was distributed between May and November 2020. The survey focused on 6 domains: participant demographics, ICU characteristics, ICU research infrastructure, motivating factors, perceived barriers, and perceived facilitators. Responses were received from 73 community ICU stakeholders, representing 18 ICUs. 7/18 ICUs had a clinical research program. Participants rated their interest in pandemic research at a mean of 5.2 (Standard Deviation SD = 1.9) on a 7-point Likert scale from 'not interested' to 'very interested'. The strongest motivating factor for research participation was the belief that research improves clinical care and outcomes. The most significant facilitators of research involvement were the availability of an experienced research coordinator and dedicated external funding to cover start-up costs, while the most significant barriers to research involvement were a lack of start-up funding for a research coordinator and a lack of ICU research experience. Canadian Community ICU stakeholders are interested in participating in pandemic research but lack basic infrastructure, research personnel, research experience and start-up funding. Evolution of a research support model at community hospitals, where most patients receive acute care, may increase research participation and improve the generalizability of funded research in Canada.
Noninvasive ventilation has been studied as a means of reducing complications among patients being weaned from invasive mechanical ventilation. We sought to summarize evidence comparing noninvasive ...and invasive weaning and their effects on mortality.
We identified relevant randomized and quasirandomized trials through searches of databases, conference proceedings and grey literature. We included trials comparing extubation and immediate application of noninvasive ventilation with continued invasive weaning in adults on mechanical ventilation. Two reviewers each independently screened citations, assessed trial quality and abstracted data. Our primary outcome was mortality.
We identified 16 trials involving 994 participants, most of whom had chronic obstructive pulmonary disease (COPD). Compared with invasive weaning, noninvasive weaning significantly reduced mortality (risk ratio RR 0.53, 95% confidence interval CI 0.36 to 0.80), weaning failures (RR 0.63, 95% CI 0.42 to 0.96), ventilator-associated pneumonia (RR 0.25, 95% CI 0.15 to 0.43), length of stay in the intensive care unit (mean difference MD -5.59 d, 95% CI -7.90 to -3.28) and in hospital (MD -6.04 d, 95% CI -9.22 to -2.87), and total duration of mechanical ventilation (MD -5.64 d, 95% CI -9.50 to -1.77). Noninvasive weaning had no significant effect on the duration of ventilation related to weaning, but significantly reduced rates of tracheostomy (RR 0.19, 95% CI 0.08 to 0.47) and reintubation (RR 0.65, 95% CI 0.44 to 0.97). Mortality benefits were significantly greater in trials enrolling patients with COPD than in trials enrolling mixed patient populations (RR 0.36 95% CI 0.24 to 0.56 v. RR 0.81 95% CI 0.47 to 1.40).
Noninvasive weaning reduces rates of death and pneumonia without increasing the risk of weaning failure or reintubation. In subgroup analyses, mortality benefits were significantly greater in patients with COPD.
In patients with severe acute kidney injury (AKI) but no urgent indication for renal replacement therapy (RRT), the optimal time to initiate RRT remains controversial. While starting RRT preemptively ...may have benefits, this may expose patients to unnecessary RRT. To study this, we conducted a 12-center open-label pilot trial of critically ill adults with volume replete severe AKI. Patients were randomized to accelerated (12 h or less from eligibility) or standard RRT initiation. Outcomes were adherence to protocol-defined time windows for RRT initiation (primary), proportion of eligible patients enrolled, follow-up to 90 days, and safety in 101 fully eligible patients (57 with sepsis) with a mean age of 63 years. Median serum creatinine and urine output at enrollment were 268 micromoles/l and 356 ml per 24 h, respectively. In the accelerated arm, all patients commenced RRT and 45/48 did so within 12 h from eligibility (median 7.4 h). In the standard arm, 33 patients started RRT at a median of 31.6 h from eligibility, of which 19 did not receive RRT (6 died and 13 recovered kidney function). Clinical outcomes were available for all patients at 90 days following enrollment, with mortality 38% in the accelerated and 37% in the standard arm. Two surviving patients, both randomized to standard RRT initiation, were still RRT dependent at day 90. No safety signal was evident in either arm. Our findings can inform the design of a large-scale effectiveness randomized control trial.
Background Dialysis-requiring acute kidney injury (AKI) is common among critically ill patients, but little is known about trends in the incidence and outcomes of this condition over time. Study ...Design Population-based cohort study. Setting & Participants All adult patients admitted to an intensive care unit in Ontario, Canada, 1996 to 2010. Predictor Year and era (1996-2000, 2001-2005, and 2006-2010) of cohort entry. Outcomes Mortality and dialysis dependence, each evaluated at 90 and 365 days after initiation of dialysis therapy for AKI. Measurements The annual incidence proportion of dialysis-requiring AKI was evaluated and patients with this condition were characterized by era. Associations between era and the outcomes of interest were evaluated with Cox proportional hazards (for time to death) and logistic regression (for dialysis dependence), with adjustment for relevant demographic and clinical variables. Results The annual incidence of dialysis-requiring AKI among critically ill patients increased from 0.8% in 1996 to 3.0% in 2010 ( P for trend < 0.001). 90-day mortality declined from 50% in 1996 to 2000 to 45% in 2006 to 2010 (adjusted HR, 0.83 95% CI, 0.79-0.87 compared to 1996-2000). Dialysis dependence among surviving patients at 90 days was marginally lower in 2006 to 2010 (25.1%) compared to 1996 to 2000 (27.2%), but after adjustment for confounding factors, was not significantly different (adjusted OR, 0.91; 95% CI, 0.80-1.03). Limitations Unmeasured confounding by factors that may have changed in patients with dialysis-requiring AKI during the different eras; data set does not allow for mechanistic explanation for the findings; and lack of access to laboratory investigations after hospital discharge. Conclusions The incidence proportion of dialysis-requiring AKI among critically ill patients increased by almost 4-fold between 1996 and 2010. This was accompanied by a significant decline in mortality, but the risk of long-term dialysis dependence continues to affect a substantial minority of surviving patients with no clear evidence of improvement over time.
Accurate prognostic information in patients with severe traumatic brain injury remains limited, but mortality following the withdrawal of life-sustaining therapies is high and variable across ...centers. We designed a survey to understand attitudes of physicians caring for patients with severe traumatic brain injury toward the determination of prognosis and clinical decision making on the level of care.
We conducted a cross-sectional study of intensivists, neurosurgeons, and neurologists that participate in the care of patients with severe traumatic brain injury at all Canadian level 1 and level 2 trauma centers.
None.
The main outcome measure was physicians' perceptions of prognosis and recommendations on the level of care.
Our response rate was 64% (455/712). Most respondents (65%) reported that an accurate prediction of prognosis would be most helpful during the first 7 days. Most respondents (>80%) identified bedside monitoring, clinical exam, and imaging to be useful for evaluating prognosis, whereas fewer considered electrophysiology tests (<60%) and biomarkers (<15%). In a case-based scenario, approximately one-third of respondents agreed, one-third were neutral, and one-third disagreed that the patient prognosis would be unfavorable at one year. About 10% were comfortable recommending withdrawal of life-sustaining therapies.
A significant variation in perceptions of neurologic prognosis and in clinical decision making on the level of care was found among Canadian intensivists, neurosurgeons, and neurologists. Improved understanding of the factors that can accurately predict prognosis for patients with traumatic brain injury is urgently needed.
The question stem is the statement or question to which a response is sought. Each question should focus on a single construct. Question stems should contain fewer than 20 words and be easy to ...understand and interpret,5,13 nonjudgmental and unbiased.13 Investigators should phrase questions in a socially and culturally sensitive manner. They should avoid absolute terms (e.g., "always," "none" or "never"),11 abbreviations and complex terminology.2 Investigators should specify the perspective from which questions should be addressed, particularly for questions about attitudes that may elicit different responses depending on how they are worded.14 The language used influences the response formats used, which may affect the response rate. Demonstrative questions are often followed by binary responses, whereas question stems requesting respondents to rank items or elicit their opinions should adopt a neutral tone. The wording of the question and the order of response categories can influence the responses obtained.3,15 Moreover, the manner in which question stems and responses are synthesized and presented can influence potential respondents' decisions to initiate and complete a questionnaire.3 * "Other" response options: Providing an "other" response option or requesting "any other comments" allows for unanticipated answers, alters the power balance between investigators and respondents,18 and may enhance response rates to self-administered questionnaires.3 During questionnaire testing, "other" response options can help to identify new issues or elaborate on closed response formats.18 Members of the ACCADEMY (Academy of Critical Care: Development, Evaluation and Methodology) Group: Dr. Neill K.J. Adhikari, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute and Interdepartmental Division of Critical Care, Toronto, Ont.; Donald Arnold, Department of Medicine, McMaster University, Hamilton, Ont.; Dr. Karen E.A. Burns, St. Michael's Hospital, the Interdepartmental Division of Critical Care, Keenan Research Centre and the Li Ka Shing Knowledge Institute, Toronto, Ont.; Dr. Karen Choong, Department of Pediatrics and Division of Critical Care, McMaster Children's Hospital, Hamilton, Ont.; Dr. Deborah J. Cook MD MSc, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.; Dr. Cynthia Cupido, Department of Pediatrics and Division of Critical Care, McMaster Children's Hospital, Hamilton, Ont.; Ines De Campos RN, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont., and St. Michael's Hospital, Toronto, Ont.; Dr. Mark Duffett BScPharm, Department of Pharmacy and Division of Critical Care, McMaster Children's Hospital, and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.; Dr. Francois Lamontagne, Department of Clinical Epidemiology and Biostatics, McMaster University, Hamilton, Ont.; Dr. Wendy Lim, Department of Medicine, McMaster University, Hamilton, Ont.; and Dr. Maureen O. Meade MD MSc, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.
Purpose
In a national cross-sectional survey, we aimed to i) characterize work profile, workload, and income, ii) evaluate work satisfaction, work-life integration, burnout, incivility, mentorship, ...and promotion, iii) gauge future physician resource requirements, and iv) assess for differences by gender and specialty (adult
vs
pediatric).
Methods
We developed, tested, and administered an electronic questionnaire.
Results
We analyzed 265 fully and 18 partially completed questionnaires. Respondents were predominantly men (192; 72.5%) and adult intensivists (229; 87.7%). Most intensivists (226/272; 83.1%) were somewhat satisfied or strongly satisfied with their career. Over one third of respondents felt that their daily intensive care unit (ICU) clinical work (113/270; 41.9%), yearly non-ICU clinical work (86/248; 34.7%), administrative work (101/264; 38.3%), and in-house call coverage (78/198; 39.4%) were somewhat high or very high. Nearly half (129/273; 47.3%) felt that their work schedule did not leave enough time for personal/family life. Twenty-seven percent (74/272) of respondents were experiencing at least one symptom of burnout when surveyed and 171/272 (63%) experienced burnout symptoms more than once a month. Ten percent planned to retire in the next five years and 17-20% retired each five-year interval thereafter. Compared with men, women felt that their work schedule left significantly less time for personal/family life (χ
2
4 = 11.36,
P
< 0.05, odds ratio OR = 0.55), experienced more frequent and severe burnout symptoms (F 1,120.91 = 8.04,
P
< 0.01, OR = 2.0; F 1,112.80 = 4.91,
P
< 0.05, OR = 1.9), and more incivility in their division (χ
2
1 = 13.73,
P
< 0.001, OR = 2.8), hospital (χ
2
1 = 8.11,
P
< 0.01, OR = 2.2), and university (χ
2
1 = 4.91,
P
< 0.05, OR = 2.3).
Conclusions
Although most intensivists were satisfied with their careers, many were dissatisfied with their workload, experienced work-life integration challenges, and acknowledged burnout symptoms. Women intensivists were significantly less satisfied with their careers, experienced greater work-life integration challenges, more frequent and severe burnout symptoms, and greater incivility.
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