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The adequacy of timely empiric antibiotic therapy for ventilator-associated pneumonia: an important determinant of outcome.

https://arctichealth.org/en/permalink/ahliterature129145
Source
J Crit Care. 2012 Jun;27(3):322.e7-14
Publication Type
Article
Date
Jun-2012
Author
John G Muscedere
Andrew F Shorr
Xuran Jiang
Andrew Day
Daren K Heyland
Author Affiliation
Department of Medicine, Queen's University, Kingston, Ontario, Canada. muscedej@kgh.kari.net
Source
J Crit Care. 2012 Jun;27(3):322.e7-14
Date
Jun-2012
Language
English
Publication Type
Article
Keywords
Aged
Anti-Bacterial Agents - administration & dosage
Ciprofloxacin - administration & dosage
Drug Therapy, Combination
Female
Humans
Male
Matched-Pair Analysis
Middle Aged
Multivariate Analysis
Ontario - epidemiology
Pneumonia, Ventilator-Associated - drug therapy - mortality
Retrospective Studies
Thienamycins - administration & dosage
Time Factors
Treatment Outcome
Abstract
The individual impact of timeliness vs adequacy of empiric antibiotic therapy for a clinical suspicion of ventilator-associated pneumonia (CSVAP) is unknown. Accordingly, in patients with CSVAP and timely initiation of empiric antibiotic therapy, we determined the impact of inadequate therapy (IT).
Analysis of a randomized trial of CSVAP treated empirically with meropenem or meropenem plus ciprofloxacin was done. Adequate therapy (AT) was considered present if all pathogens in the index culture were sensitive to the empiric antibiotics; IT was defined as the presence of pathogens resistant to the empiric antibiotics. A priori, for Pseudomonas sp, 2 antibiotics with activity against the organisms were required for AT to be considered present.
Of 739 patients with CSVAP, 350 had positive cultures: 313 (89.4%) had AT, and 37 (10.6%), IT. The IT group had higher intensive care unit (35.1% vs 11.8%, P = .0001) and hospital mortalities (48.7% vs 19.5%, P
PubMed ID
22137378 View in PubMed
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Handover patterns: an observational study of critical care physicians.

https://arctichealth.org/en/permalink/ahliterature128108
Source
BMC Health Serv Res. 2012;12:11
Publication Type
Article
Date
2012
Author
Roy Ilan
Curtis D LeBaron
Marlys K Christianson
Daren K Heyland
Andrew Day
Michael D Cohen
Author Affiliation
Department of Medicine and Critical Care Program, Queen's University, Kingston General Hospital, Etherington Hall, Kingston, ON, Canada, K7L 3N6. ilanr@kgh.kari.net
Source
BMC Health Serv Res. 2012;12:11
Date
2012
Language
English
Publication Type
Article
Keywords
Academic Medical Centers
Communication
Continuity of Patient Care - standards
Critical Care
Health Services Research
Humans
Intensive Care Units
Ontario
Patient Transfer - standards
Physician's Practice Patterns - standards
Prospective Studies
Time Factors
Video Recording
Abstract
Handover (or 'handoff') is the exchange of information between health professionals that accompanies the transfer of patient care. This process can result in adverse events. Handover 'best practices', with emphasis on standardization, have been widely promoted. However, these recommendations are based mostly on expert opinion and research on medical trainees. By examining handover communication of experienced physicians, we aim to inform future research, education and quality improvement. Thus, our objective is to describe handover communication patterns used by attending critical care physicians in an academic centre and to compare them with currently popular, standardized schemes for handover communication.
Prospective, observational study using video recording in an academic intensive care unit in Ontario, Canada. Forty individual patient handovers were randomly selected out of 10 end-of-week handover sessions of attending physicians. Two coders independently reviewed handover transcripts documenting elements of three communication schemes: SBAR (Situation, Background, Assessment, Recommendations); SOAP (Subjective, Objective, Assessment, Plan); and a standard medical admission note. Frequency and extent of questions asked by incoming physicians were measured as well. Analysis consisted of descriptive statistics.
Mean (± standard deviation) duration of patient-specific handovers was 2 min 58 sec (± 57 sec). The majority of handovers' content consisted of recent and current patient status. The remainder included physicians' interpretations and advice. Questions posed by the incoming physicians accounted for 5.8% (± 3.9%) of the handovers' content. Elements of all three standardized communication schemes appeared repeatedly throughout the handover dialogs with no consistent pattern. For example, blocks of SOAP's Assessment appeared 5.2 (± 3.0) times in patient handovers; they followed Objective blocks in only 45.9% of the opportunities and preceded Plan in just 21.8%. Certain communication elements were occasionally absent. For example, SBAR's Recommendation and admission note information about the patient's Past Medical History were absent from 22 (55.0%) and 20 (50.0%), respectively, of patient handovers.
Clinical handover practice of faculty-level critical care physicians did not conform to any of the three predefined structuring schemes. Further research is needed to examine whether alternative approaches to handover communication can be identified and to identify features of high-quality handover communication.
Notes
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PubMed ID
22233877 View in PubMed
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Nutrition support in the critical care setting: current practice in canadian ICUs--opportunities for improvement?

https://arctichealth.org/en/permalink/ahliterature186906
Source
JPEN J Parenter Enteral Nutr. 2003 Jan-Feb;27(1):74-83
Publication Type
Article
Author
Daren K Heyland
Deborah Schroter-Noppe
John W Drover
Minto Jain
Laurie Keefe
Rupinder Dhaliwal
Andrew Day
Author Affiliation
Department of Medicine, Queen's University, Kingston, Ontario, Canada. dkh2@post.queensu.ca
Source
JPEN J Parenter Enteral Nutr. 2003 Jan-Feb;27(1):74-83
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Aged, 80 and over
Canada
Critical Care - standards
Cross-Sectional Studies
Female
Humans
Intensive Care Units - standards
Male
Middle Aged
Nutritional Support - standards
Odds Ratio
Time Factors
Abstract
The purpose of this project was to describe current nutrition support practice in the critical care setting and to identify interventions to target for quality improvement initiatives.
We conducted a cross-sectional national survey of dietitians working in intensive care units (ICUs) across Canada to document various aspects of nutrition support practice.
Of the 79 dietitians sent study materials, 66 responded (83%). Sixteen of 66 sites (24.2%) reported the presence of a nutrition support team, and 35 of 66 (53%) used a standard enteral feeding protocol. Dietitians retrospectively abstracted data from charts of all patients in the ICU on April 18, 2001. Of 702 patients, 313 (44.6%) received enteral nutrition only, 50 (7.1%) received parenteral nutrition only, 60 (8.5%) received both, and 279 (39.7%) received no form of nutrition support. Enteral nutrition was initiated on 1.6 days (median) after admission to ICU; 10.7% of patients were initiated on day 1. Of those receiving any form of nutrition support, on average, patients received 58% of their prescribed amounts of calories and protein over the first 12 days in the ICU. Of all days on enteral feeds, patients received feeds into the small bowel on 381 of 2321 (16.4%) days. The mean head of the bed elevation for all patients was 30 degrees. Controlling for differences in patient characteristics, site factors contributing the most successful application of nutrition support included the amount of funded dietitians per ICU bed, size of ICU, and the fact that the ICU was located in an academic setting.
A significant number of critically ill patients did not receive any form of nutrition support for the study period. Those that did receive nutrition support did not meet their prescribed energy or protein needs, especially earlier in the course of their illness. Significant opportunities to improve provision of nutrition support to critically ill patients exist.
PubMed ID
12549603 View in PubMed
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Validation of the Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients: results of a prospective observational study.

https://arctichealth.org/en/permalink/ahliterature176681
Source
Crit Care Med. 2004 Nov;32(11):2260-6
Publication Type
Article
Date
Nov-2004
Author
Daren K Heyland
Rupinder Dhaliwal
Andrew Day
Minto Jain
John Drover
Author Affiliation
Department of Medicine, Queen's University, Kingston, Ontario.
Source
Crit Care Med. 2004 Nov;32(11):2260-6
Date
Nov-2004
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Aged, 80 and over
Canada
Clinical Protocols - standards
Critical Care - methods - standards - statistics & numerical data
Critical Illness - therapy
Diffusion of Innovation
Enteral Nutrition - standards - statistics & numerical data
Evidence-Based Medicine - standards
Female
Guideline Adherence - statistics & numerical data
Health Services Research
Humans
Information Dissemination
Male
Middle Aged
Needs Assessment
Nutritional Support - methods - standards - statistics & numerical data
Patient Selection
Physician's Practice Patterns - standards - statistics & numerical data
Practice Guidelines as Topic - standards
Prospective Studies
Respiration, Artificial
Abstract
Recently, evidence-based clinical practice guidelines for the provision of nutrition support in the critical care setting have been developed. To validate these guidelines, we hypothesized that intensive care units whose practice, on average, was more consistent with the guidelines would have greater success in providing enteral nutrition.
Prospective observational study.
Fifty-nine intensive care units across Canada.
Consecutive cohort of mechanically ventilated patients.
In May 2003, participating intensive care units recorded nutrition support practices on a consecutive cohort of mechanically ventilated patients who stayed for a minimum of 72 hrs. Sites enrolled an average of 10.8 (range, 4-18) patients for a total of 638. Patients were observed for an average of 10.7 days.
We examined the association between five recommendations from the clinical practice guidelines most directly related to the provision of nutrition support (use of parenteral nutrition, feeding protocol, early enteral nutrition, small bowel feedings, and motility agents) and adequacy of enteral nutrition. We defined adequacy of enteral nutrition as the percent of prescribed calories that patients actually received. Across sites, the average adequacy of enteral nutrition over the observed stay in intensive care unit ranged from 1.8% to 76.6% (average 43.0%). Intensive care units with a greater than median utilization of parenteral nutrition (>17.5% patient days) had a much lower adequacy of enteral nutrition (32.9 vs. 52.7%, p 50% of their patients within the first 48 hrs had a higher adequacy of enteral nutrition than those that did not (48.1 vs. 34.4%, p 50% utilization of motility agents and/or any small bowel feedings in patients with high gastric residuals tended to have a higher adequacy of enteral nutrition than those intensive care units that did not (45.6 vs. 39.2%, p = .04, and 48.4 vs. 41.8%, p = .16, respectively).
Intensive care units that were more consistent with the Canadian clinical practice guidelines were more likely to successfully feed patients via enteral nutrition. Adoption of the Canadian clinical practice guidelines should lead to improved nutrition support practice in intensive care units. This may translate into better outcomes for critically ill patients receiving nutrition support.
Notes
Comment In: Crit Care Med. 2004 Nov;32(11):2354-515640660
PubMed ID
15640639 View in PubMed
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