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Biomedical subjects

Deborah J Cook

Publications and source records attributed to Deborah J Cook.

At least 19 recordsLinked to original sources
PubMed2003

Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation? A systematic review of the literature.

BACKGROUND: Over the past decade, noninvasive positive-pressure ventilation (NPPV) in the setting of acute exacerbations of chronic obstructive pulmonary disease (COPD) has increased in popularity. Although several trials have been published on the relative effectiveness of this treatment, apparent inconsistencies in study results remain. PURPOSE: To assess the effect of NPPV on rate of endotracheal intubation, length of hospital stay, and in-hospital mortality rate in patients with an acute exacerbation of COPD and to determine the effect of exacerbation severity on these outcomes. DATA SOURCES: MEDLINE (1966 to 2002) and EMBASE (1990 to 2002). Additional data sources included the Cochrane Library, personal files, abstract proceedings, reference lists of selected articles, and expert contact. There were no language restrictions. STUDY SELECTION: The researchers selected randomized, controlled trials that 1) examined patients with acute exacerbation of COPD; 2) compared noninvasive ventilation and standard therapy with standard therapy alone; and 3) included need for endotracheal intubation, length of hospital stay, or hospital survival as an outcome. DATA EXTRACTION: Methodologic quality and results were abstracted independently and in duplicate. DATA SYNTHESIS: The addition of NPPV to standard care in patients with an acute exacerbation of COPD decreased the rate of endotracheal intubation (risk reduction, 28% [95% CI, 15% to 40%]), length of hospital stay (absolute reduction, 4.57 days [CI, 2.30 to 6.83 days]), and in-hospital mortality rate (risk reduction, 10% [CI, 5% to 15%]). However, subgroup analysis showed that these beneficial effects occurred only in patients with severe exacerbations, not in those with milder exacerbations. CONCLUSIONS: Patients with severe exacerbations of COPD benefit from the addition of NPPV to standard therapy. However, NPPV has not been shown to benefit hospitalized patients with milder COPD exacerbations.

Hospital Mortality↗
PubMed2003

Procalcitonin as a diagnostic test for sepsis: health technology assessment in the ICU.

Elevation in the serum concentration of procalcitonin (PCT) is associated with systemic infection. This association has led to the proposed use of PCT as a novel biomarker of bacterial sepsis. The advantages and limitations of the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) definitions of sepsis are an important consideration that affects the impact of any diagnostic test for sepsis and these issues are discussed. Our main objective is to perform a systematic health technology assessment of PCT as a diagnostic test for sepsis. In an adult intensive care unit (ICU) population, we identify a specific and important question-can PCT accurately distinguish sepsis in patients with systemic inflammatory response syndrome (SIRS) who have a suspected infection? Likelihood ratios are calculated from published data to attempt to find the best answer. The published evidence does not support a general claim that PCT is a useful decision support tool for diagnosing sepsis in patients who have SIRS. Procalcitonin has a slightly better ability to exclude the diagnosis of sepsis. The role for using PCT testing in the ICU will continue to evolve along with our understanding and definition of sepsis.

Biomarkers↗
PubMed2003

Health technology assessment in the ICU: noninvasive positive pressure ventilation for acute respiratory failure.

Critical care practitioners have a number of health-related technologies at our disposal to provide the best possible care for our critically ill patients. Although certain technologies may improve outcomes in the intensive care unit (ICU), many technologies are disseminated without rigorous evaluation. Health technology assessment (HTA) in critical care is a complex and dynamic process, which is a powerful tool to assess a health technology for its initial use or continued application in the ICU. This article applies an HTA framework to the use of noninvasive positive pressure ventilation (NPPV) for patients with acute respiratory failure (ARF). The strongest evidence to date supports the use of NPPV in patients with ARF caused by exacerbations of chronic obstructive pulmonary disease (COPD); the benefit for patients with acute nonhypercarbic, hypoxemic respiratory failure is less clear. The success of NPPV technology depends on operator education and experience. The cost effectiveness of NPPV has been evaluated in patients with ARF caused by COPD, and cost reduction is attributed to the prevention of ventilator-associated pneumonia by avoiding endotracheal intubation. An HTA framework can help health care practitioners make important decisions regarding the acquisition of new technologies and the evaluation of current technologies. Careful evaluation of health technologies in the ICU should be an ongoing priority.

Acute Disease↗
PubMed2003

Seasonal bed closures in an intensive care unit: a qualitative study.

OBJECTIVE: To describe perceptions of the administrative procedures for seasonal bed closures and their consequences in the intensive care unit (ICU), and to critique this example of health care priority setting for legitimacy and fairness. DESIGN: A qualitative study using case study methods and interviews with key participants. We evaluated fairness and legitimacy of the bed closure process using 4 domains of the ethical framework of "accountability for reasonableness." SETTING: An university-affiliated medical/surgical ICU in Eastern Canada. PARTICIPANTS: ICU clinicians (9 bedside nurses and 5 physicians), and administrators (3 ICU managers and 2 senior hospital executives). MAIN OUTCOME MEASURES: Perceptions of ICU clinicians and administrators regarding the ICU bed closure decision-making process and its consequences. RESULTS: Emerging themes concerned: (1) bed closure rationale (including arbitrary decision making, bed closure masquerading as a code for a nursing shortage, and suboptimal evidence base for implementing closures); (2) bed closure process (viewed as unclear with insufficient prior publicity and inadequate subsequent review); and (3) adverse consequences (including safety issues, negative professional working relationships, and poor morale). Although an appeals mechanism existed, nurses were not available to staff reopened beds so this condition is only partially met. The relevance, publicity, and enforcement conditions for accountability of reasonableness were not satisfied, offering opportunities for improvement. CONCLUSION: Clinicians and administrators are readily able to identify shortcomings in the seasonal bed closure process in the ICU. These shortcomings should be targeted for improvement so that intensive care health services delivery is legitimate and fair.

Decision Making↗
PubMed2003

Prognostic value of myocardial perfusion studies in patients with end-stage renal disease assessed for kidney or kidney-pancreas transplantation: a meta-analysis.

The prognostic utility of myocardial perfusion studies (MPS) such as thallium scintigraphy and dobutamine stress echocardiography (DSE) for stratifying cardiac risk among candidates for kidney or kidney-pancreas transplantation is uncertain. This study is a meta-analysis to determine the prognostic significance of MPS results on future myocardial infarction (MI) and cardiac death (CD) in patients with end-stage renal disease (ESRD) assessed for kidney or kidney-pancreas transplantation. MEDLINE was searched using combinations of MeSH headings and text words for transplantation, coronary artery disease, prognosis, end-stage renal disease, and noninvasive cardiac testing (nuclear scintigraphy and DSE) for primary studies. Studies were included if they reported MPS results and cardiac events in patients assessed for kidney or kidney-pancreas transplantation. Methodologic study quality and outcome data were independently abstracted in duplicate by two researchers. The relative risks (RR) of MI and CD were calculated using a random effects model. Twelve articles met all inclusion criteria; 12 studies reported CD, and 9 reported MI. In eight studies, thallium scintigraphy was used (four with pharmacologic stress, four with exercise stress), whereas four used DSE. When compared with negative tests, positive tests had a significantly increased RR of MI (2.73 [95% CI, 1.25 to 5.97]; P = 0.01) and CD (2.92 [95% CI, 1.66 to 5.12]; P < 0.001). Subgroup analyses of studies of diabetic patients indicated that positive tests were associated with a RR of CD 3.95 (95% CI, 1.48 to 10.5; P = 0.006) and a RR of MI 2.68 (95% CI, 0.95 to 7.57; P = 0.06) when compared with negative tests. In studies evaluating mixed populations of diabetic and nondiabetic patients, positive tests were associated with a RR of CD 2.52 (95% CI, 1.25 to 5.08; P = 0.01) and with a RR of MI 2.79 (95% CI, 0.85 to 9.21; P = 0.09) when compared with a negative test. The presence of reversible defects was associated with an increased risk of MI in diabetic patients and of CD in both subgroups; fixed defects were associated with an increased risk of CD but not MI. It is concluded that positive MPS are useful in identifying patients with significantly increased risk of future MI and CD in both diabetic and nondiabetic ESRD patients.

Coronary Circulation↗
PubMed2003

Methodologic issues in systematic reviews and meta-analyses.

Systematic reviews of original research are increasing in number. Systematic reviews are distinct from narrative reviews because they address a specific clinical question, require a comprehensive literature search, use explicit selection criteria to identify relevant studies, assess the methodologic quality of included studies, explore differences among study results, and either qualitatively or quantitatively synthesize study results. Systematic reviews that quantitatively pool results of more than one study are called meta-analyses. Several organizations are collaboratively involved in producing high quality systematic reviews and meta-analyses. Familiarity with how to do a systematic review and meta-analysis will lead to greater skill in using this type of article. For clinicians, teachers, and investigators, systematic reviews and meta-analyses are useful sources of evidence.

Decision Making↗
PubMed2003

Measures, markers, and mediators: toward a staging system for clinical sepsis. A report of the Fifth Toronto Sepsis Roundtable, Toronto, Ontario, Canada, October 25-26, 2000.

BACKGROUND: Sepsis is not a single disease but a complex and heterogeneous process. Its expression is variable, and its severity is influenced by the nature of the infection, the genetic background of the patient, the time to clinical intervention, the supportive care provided by the clinician, and a number of factors as yet unknown. The evaluation of effective therapies has been hampered by limitations in our ability to characterize the process and to stratify patients into more homogeneous groups with respect to pathogenesis. OBJECTIVES: To develop a taxonomy of markers relevant to clinical research in sepsis and to propose a testable candidate system for stratifying patients into more therapeutically homogeneous groups. DATA SOURCE: An expert roundtable discussion and a MEDLINE review using search terms "marker" and "sepsis." RESULTS: Markers provide information in one or more of three domains: diagnosis, prognosis, and response to therapy. More than 80 putative markers of sepsis have been described. All correlate with the risk of mortality (prognosis), yet none has shown utility in stratifying patients with respect to therapy (diagnosis) or in titrating that therapy (response). Their limitations arise from the challenges of establishing causality in a complex disease process such as sepsis and of stratifying patients into more homogeneous populations. The former limitation may be addressed through a modification of Koch's postulates to differentiate causality from simple association. The latter suggests the need for a staging system analogous to those used in other complex disease processes such as cancer. A candidate framework for such a system, based on the infection, the host response, and the extent of organ dysfunction (the IRO system) is described. CONCLUSIONS: Advances in the understanding and management of patients with sepsis will necessitate more rigorous approaches to disease description and stratification. Models should be developed, tested, and modified through clinical studies rather than through consensus.

Biomarkers↗
PubMed2003

Evaluation of a practice guideline for noninvasive positive-pressure ventilation for acute respiratory failure.

OBJECTIVES: Clinical practice guidelines have been devised to change practitioner performance and to improve the process and outcomes of care. The objective of this study was to determine whether adherence to a practice guideline on noninvasive positive-pressure ventilation (NPPV) for the treatment of patients with acute respiratory failure (ARF) would change clinician behavior and resource utilization, and improve NPPV utilization and patient outcomes. DESIGN: Using a multidisciplinary team, we developed, implemented, and evaluated an NPPV practice guideline for ARF. Before and after guideline implementation, we recorded the incidence of endotracheal intubation (ETI) and mortality. Secondary outcomes were technological settings (ie, NPPV settings and duration) and NPPV administration (ie, cardiopulmonary monitoring, transfer to and time spent in the ICU, and pulmonary consultation). PARTICIPANTS: We enrolled 189 patients, 91 in the preguideline phase and 98 in the postguideline phase. Patients were similar in the both phases with respect to diagnoses at hospital admission and severity of illness. RESULTS: Of patients receiving NPPV for ARF, 67.3% fulfilled the guideline eligibility criteria in the postguideline phase compared to 62.6% in the preguideline phase (p = 0.543). Compared to the preguideline phase, more patients in the postguideline phase were transferred to the ICU (14.7% vs 33.7%, respectively; p = 0.003), spent more time in the ICU (30.9% vs 62.4%, respectively; p < 0.0001), and had consultation by a pulmonary physician (28.4% vs 49.0%, respectively; p = 0.004). There were no changes in technological settings. Guideline implementation was associated with improved cardiopulmonary monitoring. Nursing and respiratory therapist flow sheets were well-utilized during the guideline phase. There were no differences in ETI rates and mortality rates before and after guideline implementation. CONCLUSION: In this before-after study, we found that a multidisciplinary guideline for the use of NPPV for the treatment of patients with ARF was associated with changes in the process of care, with greater NPPV utilization in the ICU, and with increased pulmonary consultation, without any significant changes in the outcomes of care (ie, ETI and mortality rates).

Acute Disease↗
PubMed2003

Dying in the ICU: perspectives of family members.

OBJECTIVE: To describe the perspectives of family members to the care provided to critically ill patients who died in the ICU. DESIGN: Multicenter, prospective, observational study. SETTING: Six university-affiliated ICUs across Canada. METHODS: Patients who received mechanical ventilation for > 48 h and who died in the ICU were eligible for this study. Three to four weeks after the patient's death, we mailed a validated questionnaire to one selected family member who made at least one visit to the patient in the ICU. We obtained self-rated levels of satisfaction with key aspects of end-of-life care, communication, and decision making, and the overall ICU experience. MAIN RESULTS: Questionnaires were mailed to 413 family members; 256 completed surveys were returned (response rate, 62.0%). In the final hours before the death of the patient, family members reported that patients were "totally comfortable" (34.8%), "very comfortable" (23.8%), or "mostly comfortable" (32.0%). Family members felt "very supported" (57.0%) and "supported" (30.7%) by the health-care team. Most (82.0%) believed that the patient's life was neither prolonged nor shortened unnecessarily. Most family members (90.4%) preferred some form of shared decision making. Overall, 52% of families rated their satisfaction with care as "excellent," 31% rated care as "very good," 10% as "good," 4% as "fair," and 2% as "poor." Overall satisfaction with end-of-life care was significantly associated with completeness of information received by the family member, respect and compassion shown to patient and family member, and satisfaction with amount or level of health care received. CONCLUSIONS: The majority of families of patients who died in participating ICUs were satisfied with the end-of-life care provided. Adequate communication, good decision making, and respect and compassion shown to both the dying patient and their family are key determinants to family satisfaction.

Aged↗
PubMed2003

Barriers to full-text publication following presentation of abstracts at annual orthopaedic meetings.

BACKGROUND: Oral presentations at national and international meetings offer an excellent forum for the dissemination of current research findings. However, publication rates of full-text articles after presentation of abstracts at international meetings have ranged from 11% to 78%, which suggests that at least 32% of the abstracts presented are never published as complete articles in peer-reviewed journals. In an effort to identify the reasons that surgeons had not had a paper published following presentation of their work at an international orthopaedic meeting, we conducted a survey of a cross section of authors of orthopaedic papers presented at a national meeting. METHODS: We retrieved all abstracts from the 1996 scientific program of the sixty-third Annual Meeting of the American Academy of Orthopaedic Surgeons. A computerized Medline and PubMed search established whether the abstract had been subsequently published as a full-text article. The authors of the abstracts that had not been subsequently published were surveyed to identify the reasons for the failure to publish. RESULTS: A total of 465 abstracts were presented at the sixty-third Annual Meeting of the American Academy of Orthopaedic Surgeons in 1996. We surveyed the authors of 306 abstracts for which we were unable to locate a subsequent full-text publication on Medline. One hundred and ninety-nine investigators (65%) responded to the questionnaire. At the time of the survey, seventy-two manuscripts had been published, thirty-two had been submitted and rejected, fourteen were under consideration by journals, seven had been accepted for publication or were in press, and three were not recalled by the investigator. In addition, seventy-one abstracts (35.7%) of the 199 had not been submitted for publication. The authors of those abstracts were asked to indicate one or more reasons why they had not submitted a manuscript for publication. Thirty-three investigators (46.5%) indicated that they lacked sufficient time for research activities, twenty-two (31.0%) reported that the study presented at the meeting in 1996 was still in progress, fourteen (19.7%) believed that the responsibility for writing the manuscript belonged to someone else, and twelve (16.9%) reported that difficulties with co-authors who would not participate had impeded the completion of the manuscript. Nine investigators (12.7%) responded that the pursuit of publication was a low priority. CONCLUSIONS: In a survey of investigators who had not had a full-text article published after presenting the abstract at a national meeting, we found that the failure to publish was due to one of three main reasons: (1) they did not have enough time to prepare a manuscript for publication (the reason most frequently given); (2) almost one-third of the studies that had not been submitted for publication were ongoing; and (3) relationships with co-authors sometimes presented a barrier to final publication. Thorough preparation before the study and the establishment of stricter guidelines to limit the presentation of preliminary data at national and international meetings may improve publication rates.

Abstracting and Indexing↗
PubMed2003

A randomized trial of an acid-peptic disease management program in a managed care environment.

OBJECTIVE: To study the effectiveness of a disease management program for patients with acid-related disorders. STUDY DESIGN: A cluster-randomized clinical trial of 406 patients comparing a disease management program with "usual practice." PATIENTS AND METHODS: Enrolled patients included those presenting with new dyspepsia and chronic users of antisecretory drugs in 8 geographically separate physician offices associated with the Orlando Health Care Group. There were 35 providers in the intervention group and 48 in the control group. The disease management program included evidence-based practice guidelines implemented by using physician champions, academic detailing, and multidisciplinary teams. Processes of care, patient symptoms, quality of life, costs, and work days lost were measured 6 months after patient enrollment. RESULTS: Compared with usual practice, disease management was associated with improvements in Helicobacter pylori testing (61% vs 9%; P = .001), use of recommended H pylori treatment regimens (96% vs 10%; P = .001), and discontinuation rates of proton pump therapy after treatment (70% vs 36%; P = .04). There were few differences in patient quality of life or symptoms between the 2 study groups. Disease management resulted in fewer days of antisecretory therapy (71.7 vs 88.1 days; P = .02) but no difference in total costs. CONCLUSION: This disease management program for patients with acid-related disorders led to improved processes of care. The effectiveness of such a program in other settings requires further study.

Adult↗
PubMed2003

Moving toward evidence-based practice.

"Evidence-based practice" involves applying the best available evidence to the care of individuals. Explicit, systematic methods have developed for determining what is the best available evidence. However, often even the highest-level evidence is not thoroughly or effectively used in practice, even if it is widely known. We must rigorously and critically analyze study results to understand their strengths, limitations, and generalizability, and bear in mind that our knowledge will evolve and thereby change our practice. The clinical question is not always how to apply the evidence but whether the available evidence applies to a particular patient. We should always ask whether the right provider is doing the right thing for the right patient at the right time in the right setting with the right resources.

Evidence-Based Medicine↗
PubMed2002

Central venous catheters and upper-extremity deep-vein thrombosis complicating immune heparin-induced thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is a transient antibody-mediated hypercoagulability state strongly associated with lower-limb deep-vein thrombosis (DVT). Whether HIT is additionally associated with upper-limb DVT--either with or without central venous catheter (CVC) use--is unknown. We therefore studied 260 patients with antibody-positive HIT to determine the influence of CVC use on frequency and localization of upper-extremity DVT in comparison with 2 non-HIT control populations (postoperative orthopedic surgery and intensive-care unit patients). Compared with the control populations, both upper- and lower-extremity DVTs were found to be associated with HIT. Upper-extremity DVTs occurred more frequently in HIT patients with a CVC (14 of 145 [9.7%]) versus none of 115 (0%) patients without a CVC (P =.000 35). All upper-extremity DVTs occurred at the CVC site (right, 12; left, 2; kappa = 1.0; P =.011). We conclude that a localizing vascular injury (CVC use) and a systemic hypercoagulability disorder (HIT) interact to explain upper-extremity DVT complicating HIT.

Arm↗
PubMed2002

Decision-making in the ICU: perspectives of the substitute decision-maker.

OBJECTIVE: To describe the substitute decision-makers' perspectives related to decision-making in the intensive care unit (ICU) and to determine those variables associated with their overall satisfaction with decision-making. DESIGN: Prospective, multicenter, cohort study. SETTING: Six Canadian university-affiliated ICUs. PATIENTS AND PARTICIPANTS: We distributed a validated, self-administered questionnaire assessing 21 key aspects of communication and decision-making to substitute decision-makers of ICU patients who were mechanically ventilated for more than 48 h. INTERVENTION: None. MEASUREMENTS AND RESULTS: A group consisting of 1,123 substitute decision-makers received questionnaires; 789 were returned (70.3% response rate). Respondents were most satisfied with the frequency of communication with nurses and least satisfied with the frequency of communication with physicians. In terms of overall satisfaction with decision-making, 560 (70.9%) of the respondents were either completely or very satisfied. The majority (81.2%) of respondents preferred some form of shared decision-making process. Factors contributing the most to satisfaction with decision-making included: complete satisfaction with level of health care the patient received, completeness of information received, and feeling supported through the decision-making process. Satisfaction with decision-making varied significantly across sites. CONCLUSIONS: In this multicenter observational study, we found that most substitute decision-makers for ICU patients wanted to share decision-making responsibility with physicians and that, overall, they were satisfied with their decision-making experience. Adequate communication, feeling supported, and achieving the appropriate level of care for their family member were key determinants of satisfaction with decision-making in the ICU.

Canada↗
PubMed2002

Comparison of mortality between private for-profit and private not-for-profit hemodialysis centers: a systematic review and meta-analysis.

CONTEXT: Private for-profit and private not-for-profit dialysis facilities provide the majority of hemodialysis care in the United States. There has been extensive debate about whether the profit status of these facilities influences patient mortality. OBJECTIVE: To determine whether a difference in adjusted mortality rates exists between hemodialysis patients receiving care in private for-profit vs private not-for-profit dialysis centers. DATA SOURCES: We searched 11 bibliographic databases, reviewed our own files, and contacted experts in June 2001-January 2002. In June 2002, we also searched PubMed using the "related articles" feature, SciSearch, and the reference lists of all studies that fulfilled our eligibility criteria. STUDY SELECTION: We included published and unpublished observational studies that directly compared the mortality rates of hemodialysis patients in private for-profit and private not-for-profit dialysis centers and provided adjusted mortality rates. We masked the study results prior to determining study eligibility, and teams of 2 reviewers independently evaluated the eligibility of all studies. Eight observational studies that included more than 500 000 patient-years of data fulfilled our eligibility criteria. DATA EXTRACTION: Teams of 2 reviewers independently abstracted data on study characteristics, sampling method, data sources, and factors controlled for in the analyses. Reviewers resolved disagreements by consensus. DATA SYNTHESIS: The studies reported data from January 1, 1973, through December 31, 1997, and included a median of 1342 facilities per study. Six of the 8 studies showed a statistically significant increase in adjusted mortality in for-profit facilities, 1 showed a nonsignificant trend toward increased mortality in for-profit facilities, and 1 showed a nonsignificant trend toward decreased mortality in for-profit facilities. The pooled estimate, using a random-effects model, demonstrated that private for-profit dialysis centers were associated with an increased risk of death (relative risk, 1.08; 95% confidence interval, 1.04-1.13; P<.001). This relative risk suggests that there are annually 2500 (with a plausible range of 1200-4000) excessive premature deaths in US for-profit dialysis centers. CONCLUSIONS: Hemodialysis care in private not-for-profit centers is associated with a lower risk of mortality compared with care in private for-profit centers.

Health Services Research↗
PubMed2002

A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals.

BACKGROUND: Canadians are engaged in an intense debate about the relative merits of private for-profit versus private not-for-profit health care delivery. To inform this debate, we undertook a systematic review and meta-analysis of studies comparing the mortality rates of private for-profit hospitals and those of private not-for-profit hospitals. METHODS: We identified studies through an electronic search of 11 bibliographical databases, our own files, consultation with experts, reference lists, PubMed and SciSearch. We masked the study results before determining study eligibility. Our eligibility criteria included observational studies or randomized controlled trials that compared private for-profit and private not-for-profit hospitals. We excluded studies that evaluated mortality rates in hospitals with a particular profit status that subsequently converted to the other profit status. For each study, we calculated a relative risk of mortality for private for-profit hospitals relative to private not-for-profit hospitals and pooled the studies of adult populations that included adjustment for potential confounders (e.g., teaching status, severity of illness) using a random effects model. RESULTS: Fifteen observational studies, involving more than 26 000 hospitals and 38 million patients, fulfilled the eligibility criteria. In the studies of adult populations, with adjustment for potential confounders, private for-profit hospitals were associated with an increased risk of death (relative risk [RR] 1.020, 95% confidence interval [CI] 1.003-1.038; p = 0.02). The one perinatal study with adjustment for potential confounders also showed an increased risk of death in private for-profit hospitals (RR 1.095, 95% CI 1.050-1.141; p < 0.0001). INTERPRETATION: Our meta-analysis suggests that private for-profit ownership of hospitals, in comparison with private not-for-profit ownership, results in a higher risk of death for patients.

Hospital Mortality↗
PubMed2002

Prevention of ventilator-associated pneumonia: current practice in Canadian intensive care units.

OBJECTIVE: To evaluate the current use of strategies to prevent ventilator-associated pneumonia (VAP) and to identify interventions to target for quality-improvement initiatives. DESIGN: Cross-sectional national survey. SETTING: Canadian intensive care units (ICUs) with at least 8 beds. PATIENTS: Seven hundred and two patients in 66 ICUs in 10 provinces in Canada. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The Canadian Critical Care Trials Group recently developed VAP prevention guidelines. Before these guidelines were disseminated, we documented the extent to which these recommendations were followed in practice by using 3 methods: survey of ICU directors, prospective observation of patients on one day, and retrospective review of patient charts for a 12-day period. According to ICU directors, ventilator circuits were changed only for new patients or if the circuit was soiled in 7 of 66 ICUs (10%), heat and moisture exchangers were used routinely in 53 of 66 ICUs (80%), and closed-suction catheter systems were used in 58 of 66 ICUs (88%). Neither subglottic secretion drainage tubes nor prophylactic antibiotics for VAP were used at all. Of the entire cohort of 702 patients, the average degree of elevation of the head of the bed was 29.9 degrees (range, 0 degrees -90 degrees ) and 22 of 702 (3.1%) were observed to be on a kinetic bed. Of the 459 patients receiving any form of mechanical ventilation, 56 (12.2%) were receiving noninvasive or mask ventilation, 262 (57.1%) were orally intubated, 9 (1.9%) were nasally intubated, and 132 (28.8%) had received a tracheostomy. Of the 423 patients who received nutrition support, 373 (88.2%) received enteral nutrition. Small bowel feeding tubes were used during 16.4% of study days on enteral feeds and sucralfate was prescribed for 1.7% of study days. CONCLUSIONS: Significant opportunities exist to improve VAP prevention practices in Canada. These strategies include decreasing the frequency of ventilator circuit changes, and increasing the use of non-invasive ventilation, subglottic secretion drainage endotracheal tubes, kinetic bed therapy, small bowel feedings, and elevation of the head of the bed.

Adolescent↗