To determine physicians' stated practices regarding the use of bilevel noninvasive ventilation (NIV) for acute respiratory failure and the predictors of practice variation.
Cross-sectional postal survey.
Province of Ontario, Canada.
Attending physicians and residents in four specialties at 15 teaching hospitals.
We used literature searches and focus groups to design questions related to NIV utilization with respect to frequency, location of and indications for use, awareness of supporting literature, and perceived efficacy. We assessed the survey's clinical sensibility and reliability. We used regression analyses to evaluate practice variation among hospitals and specialties and to determine predictors of more frequent NIV use, initiation of and continued use in nonmonitored settings, and use for specific indications.
Three hundred eighty-five (48%) of 808 physicians responded; 242 used NIV. The two most common indications for NIV use were chronic obstructive pulmonary disease and congestive heart failure. NIV guidelines, protocols, or policies were available in 12 of 15 hospitals. We found variation in NIV utilization among specialties but not hospitals. Specialty (critical care and respirology versus internal and emergency medicine), fewer years of postgraduate experience, and a greater number of noninvasive ventilators were predictors of more frequent NIV use (all p
Comment In: Crit Care Med. 2005 Jul;33(7):1642-316003076
This systematic review included controlled clinical trials comparing tracheal intubation (TI) with alternative airway techniques (AAT) (bag mask ventilation and use of extraglottic devices) performed by paramedics in the prehospital setting. A priori outcomes to be assessed were survival, neurologic outcome, airway management success rates and complications. We identified trials using EMBASE, MEDLINE, CINAHL, The Cochrane Library, Web of Science, author contacts and hand searching. We included 5 trials enrolling a total of 1559 patients. No individual study showed any statistical difference in outcomes between the TI and AAT groups. Because of study heterogeneity, we did not pool the data. This is the most comprehensive review to date on paramedic trials. Owing to the heterogeneity of prehospital systems, administrators of each system must individually consider their airway management protocols.
We sought to develop and validate a three-station simulation-based Objective Structured Clinical Examination (OSCE) tool to assess emergency medicine resident competency in resuscitation scenarios.
An expert panel of emergency physicians developed three scenarios for use with high-fidelity mannequins. For each scenario, a corresponding assessment tool was developed with an essential actions (EA) checklist and a global assessment score (GAS). The scenarios were (1) unstable ventricular tachycardia, (2) respiratory failure, and (3) ST elevation myocardial infarction. Emergency medicine residents were videotaped completing the OSCE, and three clinician experts independently evaluated the videotapes using the assessment tool.
Twenty-one residents completed the OSCE (nine residents in the College of Family Physicians of Canada-Emergency Medicine [CCFP-EM] program, six junior residents in the Fellow of the Royal College of Physicians of Canada-Emergency Medicine [FRCP-EM] program, six senior residents in the FRCP-EM). Interrater reliability for the EA scores was good but varied between scenarios (Spearman rho =  0.68,  0.81,  0.41). Interrater reliability for the GAS was also good, with less variability (rho =  0.64,  0.56,  0.62). When comparing GAS scores, senior FRCP residents outperformed CCFP-EM residents in all scenarios and junior residents in two of three scenarios (p
Recommendations for acceptable emergency department (ED) length of stay (LOS) vary internationally with = 8 h generally considered acceptable. Protracted ED LOS may place critically ill patients requiring mechanical ventilation at increased risk of adverse events as most EDs are not resourced for longitudinal delivery of critical care. Our objective was to quantify the ED LOS for mechanically ventilated patients (invasive and/or non-invasive ventilation [NIV]) and to explore patient and system level predictors of prolonged ED LOS. Additionally, we aimed to describe delivery and monitoring of ventilation in the ED.
Prospective observational study of ED LOS for all patients receiving mechanical ventilation at four metropolitan EDs in Toronto, Canada over two six-month periods in 2009 and 2010.
We identified 618 mechanically ventilated patients which represented 0.5% (95% CI 0.4%-0.5%) of all ED visits. Of these, 484 (78.3%) received invasive ventilation, 118 (19.1%) received NIV; 16 received both during the ED stay. Median Kaplan-Meier estimated duration of ED stay for all patients was 6.4 h (IQR 2.8-14.6). Patients with trauma diagnoses had a shorter median (IQR) LOS, 2.5 h (1.3-5.1), compared to ventilated patients with non-trauma diagnoses, 8.5 h (3.3-14.0) (p
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