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We examined the effect of an antimicrobial stewardship program (ASP), procalcitonin testing and rapid blood-culture identification on hospital mortality in a prospective quality improvement project in critically ill septic adults. Secondarily, we have reported antimicrobial guideline concordance, acceptance of ASP interventions, and antimicrobial and health-resource utilization.
Health technology reassessment (HTR) is a process to manage existing health technologies to ensure ongoing optimal use. A model to guide HTR was developed; however, there is limited practical experience. This paper addresses this knowledge gap through the completion of a multi-phase HTR of red blood cell (RBC) transfusion practices in the intensive care unit (ICU).
The HTR consisted of three phases and here we report on the final phase: the development, implementation, and evaluation of behavior change interventions aimed at addressing inappropriate RBC transfusions in an ICU.
The interventions, comprised of group education and audit and feedback, were co-designed and implemented with clinical leaders. The intervention was evaluated through a controlled before-and-after pilot feasibility study. The primary outcome was the proportion of potentially inappropriate RBC transfusions (i.e., with a pre-transfusion hemoglobin of 70 g/L or more).
There was marked variability in the monthly proportion of potentially inappropriate RBC transfusions. Relative to the pre-intervention phase, there was no significant difference in the proportion of potentially inappropriate RBC transfusions post-intervention. Lessons from this work include the importance of early and meaningful engagement of clinical leaders; tailoring the intervention modalities; and, efficient access to data through an electronic clinical information system.
It was feasible to design, implement, and evaluate a tailored, multi-modal behavior change intervention in this small-scale pilot study. However, early evaluation of the intervention revealed no change in technology use leading to reflection on the important question of how the HTR model needs to be improved.
As Canada’s population ages, frailty – with its increased risk of functional decline, deterioration in health status, and death – will become increasingly common. The physiology of frailty reflects its multisystem, multi-organ origins. About a quarter of Canadians over age 65 are frail, increasing to over half in those older than 85. Our health care system is organized around single-organ systems, impairing our ability to effectively treat people having multiple disorders and functional limitations. To address frailty, we must recognize when it occurs, increase awareness of its significance, develop holistic models of care, and generate better evidence for its treatment. Recognizing how frailty impacts lifespan will allow for integration of care goals into treatment options. Different settings in the Canadian health care system will require different strategies and tools to assess frailty. Given the magnitude of challenges frailty poses for the health care system as currently organized, policy changes will be essential.
To evaluate the incidence of hypoglycemia, hyperglycemia and blood glucose (BG) variability in brain-injured patients and their association with clinical outcomes.
Retrospective cohort study of brain-injured patients admitted to an 11- bed neurosciences intensive care unit (ICU) from January 1 to December 31, 2003.
We included 606 patients. Mean age was 52.3 years, 60.6% were male, 11.9% had diabetes mellitus, and 64% were post-operative. Seventy-five (12.4%) received intensive insulin therapy (IIT) for a median (IQR) 72 (24-154) hours. Hypoglycemia and hyperglycemia occurred in 4.6% (96.4% receiving IIT) and 9.6% (77.6% receiving IIT). Median number of episodes per patient was 3 (75% with ≥2) and 4 (81% with ≥2) for hypoglycemia and hyperglycemia. Variable glycemic control occurred in 3.8% (100% receiving IIT) with median number of 13 episodes per patient. In-hospital mortality was 16.7%, median (IQR) ICU and hospital lengths of stay were 2 (1-5) and 8 (3-19) days. Hypoglycemia, hyperglycemia and BG variability showed non-significant but consistent associations with hospital mortality and prolonged lengths of ICU and hospital stay. The rate of recurrence of episodes showed stronger and significant associations with outcome, in particular for BG variability and hyperglycemia.
Hypoglycemia, hyperglycemia and BG variability are relatively common in brain-injured patients and are associated with IIT. An increased frequency of episodes, in particular for BG variability and hyperglycemia, was associated with greater risk of both hospital death and prolonged duration of stay.
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