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Transfer of patient care from an intensive care unit (ICU) to a hospital ward is often challenging, high risk and inefficient. We assessed patient and provider perspectives on barriers and facilitators to high-quality transfers and recommendations to improve the transfer process. We conducted semistructured interviews of participants from a multicentre prospective cohort study of ICU transfers conducted at 10 hospitals across Canada. We purposively sampled 1 patient, 1 family member of a patient, 1 ICU provider, and 1 ward provider at each of the 8 English-speaking sites. Qualitative content analysis was used to derive themes, subthemes and recommendations. The 35 participants described 3 interrelated, overarching themes perceived as barriers or facilitators to high-quality patient transfers: resource availability, communication and institutional culture. Common recommendations suggested to improve ICU transfers included implementing standardized communication tools that streamline provider–provider and provider–patient communication, using multimodal communication to facilitate timely, accurate, durable and mutually reinforcing information transfer; and developing procedures to manage delays in transfer to ensure continuity of care for patients in the ICU waiting for a hospital ward bed. Patient and provider perspectives attribute breakdown of ICU-to-ward transfers of care to resource availability, communication and institutional culture. Patients and providers recommend standardized, multimodal communication and transfer procedures to improve quality of care.

As the coronavirus disease 2019 (COVID-19) pandemic continues to grow, health care organizations have had to select appropriate personal protective equipment (PPE) for health care workers in the face of uncertainty and a strained supply chain. Although infection prevention and control experts have provided evidence-informed guidance, there has been substantial fear among health care workers that, owing to either policy or lack of supply, they may be left unduly exposed to transmission events of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19. Droplet and contact precautions with a bundle of activities including hand hygiene and use of gloves, gowns, eye protection and medical masks are typically recommended to protect against respiratory viruses. N95 respirator use is generally recommended during aerosol-generating medical procedures such as intubation. Guidelines about PPE are based on current understanding of how the SARS-CoV-2 virus is transmitted and provide a starting point for hospital infection prevention and control strategies during this pandemic.

Oxland examine the case of a 52-year-old mom presented to the emergency department because of a decreased level of consciousness 2 days after her first chemotherapy treatment for an esthesioneuroblastoma, a rare cancer arising from her nasal cavity. The patient had a nosebleed and a 2-month history of nasal congestion. For the next 10 months, she was treated for rhinosinusitis by complementary health care providers, and in the tenth month for depression. About a month before she last visited the emergency department, a computed tomography scan, taken while in emergency, had shown a large tumor in her sinuses, extending to the frontal lobes of her brain. She was admitted to hospital and, after a biopsy, received a diagnosis of esthesioneuroblastoma. On this presentation, she was intubated, treated with mannitol and dexamethasone, and transferred to the intensive care unit (ICU) in the hope that she would improve enough to be able to receive a second round of chemotherapy. Unfortunately, during her 6-day ICU stay, her neurologic status deteriorated and she never regained consciousness.

Very elderly (80 years of age and above) critically ill patients admitted to medical intensive care units (ICUs) have a high incidence of mortality, prolonged hospital length of stay, and living in a dependent state should they survive. The objective was to develop a clinical prediction tool for hospital mortality to improve future end-of-life decision making for very elderly patients who are admitted to Canadian ICUs. This was a prospective, multicenter cohort study. Data from 1033 very elderly medical patients admitted to 22 Canadian academic and nonacademic ICUs were analyzed. A univariate analysis of selected predictors to ascertain prognostic power was performed, followed by multivariable logistic regression to derive the final prediction tool. We included 1033 elderly patients in the analyses. Mean age was 84.6±3.5 years, 55% were male, mean Acute Physiology and Chronic Health Evaluation II score was 23.1±7.9, Sequential Organ Failure Assessment score was 5.3±3.4, median ICU length of stay was 4.1 (interquartile range, 6.2) days, median hospital length of stay was 16.2 (interquartile range, 25.0) days, and ICU mortality and all-cause hospital mortality were 27% and 41%, respectively. Important predictors of hospital mortality at the time of ICU admission include age (85-90 years of age had an odds ratio of hospital mortality of 1.63 [1.04-2.56]; >90 years of age had an odds ratio of hospital mortality of 2.64 [1.27-5.48]), serum creatinine (120-300 had an odds ratio of hospital mortality of 1.57 [1.01-2.44]; >300 had an odds ratio of hospital mortality of 5.29 [2.43-11.51]), Glasgow Coma Scale (13-14 had an odds ratio of hospital mortality of 2.09 [1.09-3.98]; 8-12 had an odds ratio of hospital mortality of 2.31 [1.34-3.97]; 4-7 had an odds ratio of hospital mortality of 5.75 [3.02-10.95]; 3 had an odds ratio of hospital mortality of 8.97 [3.70-21.74]), and serum pH (<7.15 had an odds ratio of hospital mortality of 2.44 [1.07-5.60]). We identified high-risk characteristics for hospital mortality in the elderly population and developed a Risk Scale that may be used to inform discussions regarding goals of care in the future. Further study is warranted to validate the Risk Scale in other settings and evaluate its impact on clinical decision making. [Display omitted]

To describe and compare intensive care unit (ICU) patient family member and provider experiences, preferences, and perceptions of family participation in ICU rounds. Cross-sectional survey of ICU family members and providers of patients admitted to 4 medical-surgical ICUs from September 2014 to March 2015. Surveys were completed by 63 (62%) family members and 258 (43%) providers. Provider respondents included physicians (9%), nurses (56%), respiratory therapists (24%), and other ICU team members (11%). Although 38% of providers estimated only moderate family member interest in participating in rounds, 97% of family members expressed high interest. Family members and providers reported listening (95% vs 96%; P=.594) and sharing information about the patient (82% vs 82%; P=.995) as appropriate roles for family members during rounds, but differed in their perceptions on asking questions (75% vs 86%; P=.043) and participating in decision making (36% vs 59%; P=.003). Compared with family members, providers were more likely to perceive family participation in rounds to cause family stress (7% vs 22%; P=.020) and confusion (0% vs 28%; P<.001). Family members and providers share some perspectives on family participation in ICU rounds although other perspectives are discordant, with implications for communication strategies and collaborative decision making.

AbstractObjectivesThe aim of this study was: (1) to adapt the time‐driven activity‐based costing (TDABC) method to emergency department (ED) ambulatory care; (2) to estimate the cost of care associated with frequently encountered ambulatory conditions; and (3) to compare costs calculated using estimated time and objectively measured time. MethodsTDABC was applied to a retrospective cohort of patients with upper respiratory tract infections, urinary tract infections, unspecified abdominal pain, lower back pain and limb lacerations who visited an ED in Québec City (Canada) during fiscal year 2015–2016. The calculated cost of care was the product of the time required to complete each care procedure and the cost per minute of each human resource or equipment involved. Costing based on durations estimated by care professionals were compared to those based on objective measurements in the field. ResultsOverall, 220 care episodes were included and 3080 time measurements of 75 different processes were collected. Differences between costs calculated using estimated and measured times were statistically significant for all conditions except lower back pain and ranged from $4.30 to $55.20 (US) per episode. Differences were larger for conditions requiring more advanced procedures, such as imaging or the attention of ED professionals. ConclusionsThe greater the use of advanced procedures or the involvement of ED professionals in the care, the greater is the discrepancy between estimated‐time‐based and measured‐time‐based costing. TDABC should be applied using objective measurement of the time per procedure.

The proportion of elderly patients is increasing, but it is unknown if there are age-based differences in care of hospitalized patients with sudden clinical deterioration. We sought to examine the relation between patient age and care for hospitalized patients experiencing sudden clinical deterioration. We identified hospitalized adults (n = 5103) in 4 hospitals with sudden clinical deteriorations triggering medical emergency team (MET) activation between January 1, 2007, and December 31, 2009. We compared intensive care unit (ICU) admission rates (within 2 hours of MET activation), goals of care (resuscitative vs nonresuscitative), and hospital mortality according to age (<50, 50-64, 65-79, and 80+ years), adjusting for patient, physician, and hospital characteristics. Age was associated with decreased likelihood of admission to ICU (P < .0001) and increased likelihood of change in goals of care (P < .0001). Compared to patients younger than 50 years, patients 80 years or older had 67% lower odds of ICU admission (odds ratio, 0.33; 95% confidence interval, 0.26-0.41) and 587% higher odds (odds ratio, 6.87; 95% confidence interval, 4.20-11.26) of having their goals of care changed to exclude resuscitation. Hospital mortality was associated with patient age, ranging from 15% to 46% (P < .0001). Patient age is associated with care for hospitalized patients with sudden clinical deterioration, suggesting that strategies to guide care of elderly patients during MET activation may be beneficial.

Performance measurement is essential for quality improvement and is inevitable in the shift to value-based payment. The National Quality Forum is an important clearinghouse for national performance measures in health care in the United States. We reviewed the National Quality Forum library of performance measures to highlight measures that are relevant to critical care medicine, and we describe gaps and opportunities for the future of performance measurement in critical care medicine. Crafting performance measures that address core aspects of critical care will be challenging, as current outcome and performance measures have problems with validity. Future quality measures will likely focus on interdisciplinary measures across the continuum of patient care.