Publications (16)59.24 Total impact
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Article: Barriers to feeding critically ill patients: A multicenter survey of critical care nurses.
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ABSTRACT: PURPOSE: The aims of this study were to describe the barriers to enterally feeding critically ill patients from a nursing perspective and to examine whether these barriers differ across centers. MATERIALS AND METHODS: A cross-sectional survey was conducted in 5 hospitals in North America. A 45-item questionnaire was administered to critical care nurses to evaluate the barriers to enterally feeding patients. RESULTS: A total of 138 of 340 critical care nurses completed the questionnaire (response rate of 41%). The 5 most important barriers to nurses were as follows: (1) other aspects of patient care taking priority over nutrition, (2) not enough feeding pumps available, (3) enteral formula not available on the unit, (4) difficulties in obtaining small bowel access in patients not tolerating enteral nutrition, and (5) no or not enough dietitian coverage during weekends and holidays. For 18 (81%) of 22 potential barriers, the rated magnitude of importance was similar across the 5 intensive care units. CONCLUSION: Nurses in our multicenter survey identified important barriers to providing adequate enteral nutrition to their critically ill patients. The importance of these barriers does not appear to differ significantly across different clinical settings. Future research is required to evaluate if tailoring interventions to overcome these identified barriers is an effective strategy of improving nutrition practice.Journal of critical care 09/2012; · 2.13 Impact Factor -
Article: Optimizing nutrition in intensive care units: empowering critical care nurses to be effective agents of change.
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ABSTRACT: Observational studies have consistently revealed wide variation in nutritional practices across intensive care units and indicated that the provision of adequate nutrition to critically ill patients is suboptimal. To date, the potential role of critical care nurses in implementing nutritional guideline recommendations and improving nutritional therapy has received little consideration. Factors that influence nurses' nutritional practices include the lack of guidelines or conflicting evidence-based recommendations pertaining to nurses' practice, strategies for implementing guidelines that are not tailored to barriers nurses face when feeding patients, strategies to communicate best evidence that do not capitalize on nurses' preference for seeking information through social interaction, prioritization of nutrition in initial and continuing nursing education, and a lack of interdisciplinary team collaboration in the intensive care unit when decisions on how to feed patients are made. Future research and quality improvement strategies are required to correct these deficits and successfully empower nurses to become nutritional champions at the bedside. Using nurses as agents of change will help standardize nutritional practices and ensure that critically ill patients are optimally fed.American Journal of Critical Care 05/2012; 21(3):186-94. · 1.66 Impact Factor -
Article: Extreme obesity and outcomes in critically ill patients.
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ABSTRACT: Recent literature suggests that obese critically ill patients do not have worse outcomes than patients who are normal weight. However, outcomes in extreme obesity (BMI ≥ 40 kg/m(2)) are unclear. We sought to determine the association between extreme obesity and ICU outcomes. We analyzed data from a multicenter international observational study of ICU nutrition practices that occurred in 355 ICUs in 33 countries from 2007 to 2009. Included patients were mechanically ventilated adults ≥ 18 years old who remained in the ICU for > 72 h. Using generalized estimating equations and Cox proportional hazard modeling with clustering by ICU and adjusting for potential confounders, we compared extremely obese to normal-weight patients in terms of duration of mechanical ventilation (DMV), ICU length of stay (LOS), hospital LOS, and 60-day mortality. Of the 8,813 patients included in this analysis, 3,490 were normal weight (BMI 18.5-24.9 kg/m(2)), 348 had BMI 40 to 49.9 kg/m(2), 118 had BMI 50 to 59.9 kg/m(2), and 58 had BMI ≥ 60 kg/m(2). Unadjusted analyses suggested that extremely obese critically ill patients have improved mortality (OR for death, 0.77; 95% CI, 0.62-0.94), but this association was not significant after adjustment for confounders. However, an adjusted analysis of survivors found that extremely obese patients have a longer DMV and ICU LOS, with the most obese patients (BMI ≥ 60 kg/m(2)) also having longer hospital LOS. During critical illness, extreme obesity is not associated with a worse survival advantage compared with normal weight. However, among survivors, BMI ≥ 40 kg/m(2) is associated with longer time on mechanical ventilation and in the ICU. These results may have prognostic implications for extremely obese critically ill patients.Chest 08/2011; 140(5):1198-206. · 5.25 Impact Factor -
Article: Early use of supplemental parenteral nutrition in critically ill patients: results of an international multicenter observational study.
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ABSTRACT: To evaluate the effect of using supplemental parenteral nutrition compared to early enteral nutrition alone on nutritional and clinical outcomes. A multicenter, observational study. Two hundred twenty-six intensive care units from 29 Countries. Mechanically ventilated critically ill adult patients that remained in the intensive care unit for >72 hrs and received early enteral nutrition within 48 hrs from admission. Data were collected on patient characteristics and daily nutrition practices for up to 12 days. Patient outcomes were recorded after 60 days. We compared the outcomes of patients who received early enteral nutrition alone, early enteral nutrition + early parenteral nutrition, and early enteral nutrition + late parenteral nutrition (after 48 hrs of admission). Cox regression analyses were conducted to determine the effect of feeding strategy, adjusted for other confounding variables, on time to being discharged alive from hospital. A total of 2,920 patients were included in this study; 2562 (87.7%) in the early enteral nutrition group, 188 (6.4%) in the early parenteral nutrition group, and 170 (5.8%) in the late parenteral nutrition group. Adequacy of calories and protein was highest in the early parenteral nutrition group (81.2% and 80.1%, respectively) and lowest in the early enteral nutrition group (63.4% and 59.3%) (p < .0001). The 60-day mortality rate was 27.8% in the early enteral nutrition group, 34.6% in the early parenteral nutrition group, and 35.3% in the late parenteral nutrition group (p = .02). The rate of patients discharged alive from hospital was slower in the group that received early parenteral nutrition (unadjusted hazard ratio 0.75, 95% confidence interval 0.59-0.96) and late parenteral nutrition (hazard ratio 0.64, 95% confidence interval 0.51-0.81) (p = .0003) compared to early enteral nutrition. These findings persisted after adjusting for known confounders. The supplemental use of parenteral nutrition may improve provision of calories and protein but is not associated with any clinical benefit.Critical care medicine 07/2011; 39(12):2691-9. · 6.37 Impact Factor -
Article: Enhanced protein-energy provision via the enteral route in critically ill patients: a single center feasibility trial of the PEP uP protocol.
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ABSTRACT: The purpose of this pilot study is to assess the feasibility, acceptability, and safety of a new feeding protocol designed to enhance the delivery of enteral nutrition (EN). In a prospective before and after study, we evaluated a new protocol compared to our standard feeding protocol. Innovative elements of the new protocol included setting daily volume based goals instead of hourly rate targets, initiating motility agents and protein supplements on Day 1, liberalizing the gastric residual volume threshold, and the option to use trophic feeds. Bedside nurses filled out questionnaires to assess the acceptability of the new approach and we assessed patients' nutritional and clinical outcomes. We enrolled 20 mechanically ventilated patients who stayed in the Intensive Care Unit for more than three days in the before group and 30 such patients in the after group. On a scale where 1 = totally unacceptable and 10 = totally acceptable, 30 nurses rated the new protocol as 7.1 (range 1 to 10) and no incidents compromising patient safety were observed. In the before group, on average, patients received 58.8% of their energy and 61.2% of their protein requirements by EN compared to 67.9% and 73.6% in the after group (P = 0.33 and 0.13). When the subgroup of patients prescribed to receive full volume feeds in the after group were evaluated (n = 18), they received 83.2% and 89.4% of their energy and protein requirements by EN respectively (P = 0.02 for energy and 0.002 for protein compared to the before group). The rates of vomiting, regurgitation, aspiration, and pneumonia were similar between the two groups. This new feeding protocol seems to be safe and acceptable to critical care nurses. The adoption of this protocol may be associated with enhanced delivery of EN but further trials are warranted to evaluate its effect on nutritional and clinical endpoints. ClinicalTrials.gov NCT01102348.Critical care (London, England) 01/2010; 14(2):R78. · 4.61 Impact Factor -
Article: Nutrition therapy in the critical care setting: what is "best achievable" practice? An international multicenter observational study.
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ABSTRACT: To describe current nutrition practices in intensive care units and determine "best achievable" practice relative to evidence-based Critical Care Nutrition Clinical Practice Guidelines. An international, prospective, observational, cohort study conducted January to June 2007. One hundred fifty-eight adult intensive care units from 20 countries. Two-thousand nine-hundred forty-six consecutively enrolled mechanically ventilated adult patients (mean, 18.6 per site) who stayed in the intensive care unit for at least 72 hrs. Data on nutrition practices were collected from intensive care unit admission to intensive care unit discharge or a maximum of 12 days. Relative to recommendations of the Clinical Practice Guidelines, we report average, best, and worst site performance on key nutrition practices. Adherence to Clinical Practice Guideline recommendations was high for some recommendations: use of enteral nutrition in preference to parenteral nutrition, glycemic control, lack of utilization of arginine-enriched enteral formulas, delivery of hypocaloric parenteral nutrition, and the presence of a feeding protocol. However, significant practice gaps were identified for other recommendations. Average time to start of enteral nutrition was 46.5 hrs (site average range, 8.2-149.1 hrs). The average use of motility agents and small bowel feeding in patients who had high gastric residual volumes was 58.7% (site average range, 0%-100%) and 14.7% (site average range, 0%-100%), respectively. There was poor adherence to recommendations for the use of enteral formulas enriched with fish oils, glutamine supplementation, timing of supplemental parenteral nutrition, and avoidance of soybean oil-based parenteral lipids. Average nutritional adequacy was 59% (site average range, 20.5%-94.4%) for energy and 60.3% (site average range, 18.6%-152.5%) for protein. Despite high adherence to some recommendations, large gaps exist between many recommendations and actual practice in intensive care units, and consequently nutrition therapy is suboptimal. We have identified "best achievable" practice that can serve as targets for future quality improvement initiatives.Critical care medicine 10/2009; 38(2):395-401. · 6.37 Impact Factor -
Article: Lost in (knowledge) translation!
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ABSTRACT: Critical care nutrition guidelines have been developed to help busy practitioners decide how to feed their critically ill patients. However, despite the publication of guidelines and efforts to disseminate and implement them, there are large gaps between what the recommendations say and what is happening at the bedside. Consequently, the nutrition therapy received by many patients remains suboptimal. Knowledge translation is a term increasingly used in healthcare to describe the process of moving evidence learned from clinical research and summarized in clinical practice guidelines to incorporation into clinical and policy decision making. In this article, knowledge about the implementation of critical care nutrition guidelines is applied to Graham et al's knowledge-to-action model to illuminate the issues pertinent to knowledge translation in critical care nutrition. This model has 2 components: knowledge creation and action. The action component consists of 8 phases of the action cycle that represent activities needed to move knowledge into practice and are derived from planned-action theory. Components of this model are illustrated via empirically derived research, commentaries, and published studies from the field of critical care nutrition. It is hoped that this article and related articles in this issue of JPEN will help critical care nutrition practitioners to better understand the often complex and convoluted road of translating knowledge into practice so that as a community we are no longer "lost" but have direction that can bring about positive changes in nutrition practice.Journal of Parenteral and Enteral Nutrition 34(6):610-5. · 3.29 Impact Factor -
Article: Understanding adherence to guidelines in the intensive care unit: development of a comprehensive framework.
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ABSTRACT: Clinical practice guidelines (CPGs) have been hailed as a useful method of translating evidence into practice. Several CPGs have been published that provide recommendations for feeding patients in the intensive care unit (ICU). Despite a rigorous development process and active dissemination of these guidelines, their impact on nutrition practice has been modest. The purpose of this study was to develop a comprehensive framework for understanding adherence to nutrition CPGs in the critical care setting. Multiple case studies were completed at 4 Canadian ICUs. Semistructured interviews were conducted with 7 key informants at each ICU site who were asked about their perceptions and attitudes toward guidelines in general and the Canadian Critical Care Nutrition CPGs specifically. Interview transcripts and related documents were analyzed qualitatively using a framework approach. The 5 key components of the developed framework were characteristics of the CPGs, the implementation process, institutional factors, provider intent, and the clinical condition of the patient. These key themes encapsulate numerous itemized factors that contribute to guideline adherence either as barriers or enablers. Adherence to nutrition CPGs is determined by a complex interaction of multiple factors that act as barriers or enablers. The comprehensive framework for adherence to CPGs in the ICU attempts to elucidate this process and provides a useful template for future research. Future quality improvement initiatives should assess local barriers to change and design interventions to overcome these barriers.Journal of Parenteral and Enteral Nutrition 34(6):616-24. · 3.29 Impact Factor -
Article: Nutrition therapy for the critically ill surgical patient: we need to do better!
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ABSTRACT: To identify opportunities for quality improvement, the nutrition adequacy of critically ill surgical patients, in contrast to medical patients, is described. International, prospective, and observational studies conducted in 2007 and 2008 in 269 intensive care units (ICUs) were combined for purposes of this analysis. Sites provided institutional and patient characteristics and nutrition data from ICU admission to ICU discharge for maximum of 12 days. Medical and surgical patients staying in ICU at least 3 days were compared. A total of 5497 mechanically ventilated adult patients were enrolled; 37.7% had surgical ICU admission diagnosis. Surgical patients were less likely to receive enteral nutrition (EN) (54.6% vs 77.8%) and more likely to receive parenteral nutrition (PN) (13.9% vs 4.4%) (P < .0001). Among patients initiating EN in ICU, surgical patients started EN 21.0 hours later on average (57.8 vs 36.8 hours, P < .0001). Consequently, surgical patients received less of their prescribed calories from EN (33.4% vs 49.6%, P < .0001) or from all nutrition sources (45.8% vs 56.1%, P < .0001). These differences remained after adjustment for patient and site characteristics. Patients undergoing cardiovascular and gastrointestinal surgery were more likely to use PN, were less likely to use EN, started EN later, and had lower total nutrition and EN adequacy rates compared with other surgical patients. Use of feeding and/or glycemic control protocols was associated with increased nutrition adequacy. Surgical patients receive less nutrition than medical patients. Cardiovascular and gastrointestinal surgery patients are at highest risk of iatrogenic malnutrition. Strategies to improve nutrition performance, including use of protocols, are needed.Journal of Parenteral and Enteral Nutrition 34(6):644-52. · 3.29 Impact Factor -
Article: Bridging the guideline-practice gap in critical care nutrition: a review of guideline implementation studies.
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ABSTRACT: Several clinical practice guidelines focusing on nutrition therapy in mechanically ventilated, critically ill patients are available to assist busy critical care practitioners in making decisions regarding feeding their patients. However, large gaps have been observed between guideline recommendations and actual practice. To be effective in optimizing nutrition practice, guideline development must be followed by systematic guideline implementation strategies. Systematic reviews of studies evaluating guideline implementation interventions outside the critical care setting found that these strategies, such as reminders, educational outreach, and audit and feedback, produce modest to moderate improvements in processes of care, with considerable variation observed both within and across studies. Unfortunately, the optimal strategies to implement guidelines in the intensive care unit are poorly understood, with scarce data available to guide our decisions on which strategies to use. The authors identified 3 cluster randomized trials evaluating the implementation of nutrition guidelines in the critical care setting. These studies demonstrated small improvements in nutrition practice, but no significant effect on patient outcomes. There are some data to suggest that tailoring guideline implementation strategies to overcome identified barriers to change might be a more effective approach than the multifaceted "one size fits all" strategy used in previous studies. Adopting this tailored approach to guideline implementation in future studies may help bridge the current guideline-practice gap and lead to significant improvements in nutrition practices and patient outcomes.Journal of Parenteral and Enteral Nutrition 34(6):653-9. · 3.29 Impact Factor -
Article: Impact of enteral feeding protocols on enteral nutrition delivery: results of a multicenter observational study.
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ABSTRACT: To evaluate the effect of enteral feeding protocols on key indicators of enteral nutrition in the critical care setting. International, prospective, observational, cohort studies conducted in 2007 and 2008 in 269 intensive care units (ICUs) in 28 countries were combined for the purposes of this analysis. The study included 5497 consecutively enrolled, mechanically ventilated, adult patients who stayed in the ICU for at least 3 days. Sites recorded the presence or absence of a feeding protocol operational in their ICU. They provided selected nutritional data on enrolled patients from ICU admission to ICU discharge for a maximum of 12 days. Sites that used a feeding protocol were compared with those that did not. On average, protocolized sites used more enteral nutrition (EN) alone (70.4% of patients vs 63.6%, P = .0036), started EN earlier (41.2 hours from admission to ICU vs 57.1, P = .0003), and used more motility agents in patients with high gastric residual volumes (64.3% of patients vs 49.0%, P = .0028) compared with sites that did not use a feeding protocol. Overall nutritional adequacy (61.2% of patients' caloric requirements vs 51.7%, P = .0003) and adequacy from EN were higher in protocolized sites compared with nonprotocolized sites (45.4% of requirements vs 34.7%, P < .0001). EN adequacy remained significantly higher after adjustment for pertinent patient and ICU level baseline characteristics. The presence of an enteral feeding protocol is associated with significant improvements in nutrition practice compared with sites that do not use such a protocol.Journal of Parenteral and Enteral Nutrition 34(6):675-84. · 3.29 Impact Factor -
Article: Attitudes and beliefs related to the Canadian critical care nutrition practice guidelines: an international survey of critical care physicians and dietitians.
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ABSTRACT: The objective of this study was to evaluate the attitudes of critical care practitioners toward the Canadian Critical Care Nutrition Clinical Practice Guidelines (CPGs) and compare them with actual practice. An international Web-based survey was conducted. Respondents were asked to rate their strength of recommendation for 26 nutrition practices included in the Canadian CPGs. Attitudinal results were compared with actual practice on each recommendation. 514 practitioners from 27 countries completed the survey. The majority (91.4%) considered nutrition therapy to be very important for critically ill patients. There was strong endorsement for the following established practices: enteral nutrition (EN) used in preference to parenteral nutrition (PN), use of polymeric solutions and feeding protocols, and avoiding hyperglycemia. There was also strong endorsement for the following practices that are not routinely done in actual practice: EN initiated within 24 to 48 hours of admission, use of motility agents, head-of-bed elevation, use of glutamine and antioxidants, and maximizing EN before starting PN. There was diversity of opinion on the recommendations pertaining to arginine-supplemented diets, small bowel feeding, use of pharmaconutrients, intensive insulin therapy, and withholding soybean oil lipids in PN solutions and hypocaloric PN. Overall, attitudes toward the Canadian CPGs were positive. However, we identified some areas where there was diversity of opinion, highlighting a need for further research and education. System tools may be a useful strategy to integrate guideline recommendations into practice where there is strong endorsement but the recommendation is not happening in actual practice.Journal of Parenteral and Enteral Nutrition 34(6):685-96. · 3.29 Impact Factor -
Article: Creating a culture of clinical excellence in critical care nutrition: the 2008 "Best of the Best" award.
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ABSTRACT: To develop, validate, and implement a system to reward top performers in critical care nutrition practice and to illuminate characteristics of top-performing intensive care units (ICUs). An international, prospective, observational, cohort study conducted in May 2008. Setting: 179 ICUs from 18 countries. Patients: 2956 consecutively enrolled mechanically ventilated adult patients who stayed in the ICU for at least 72 hours. Interventions: To qualify for the "Best of the Best" (BOB) award, sites had to have implemented a nutrition protocol and contributed complete data on a minimum of 20 patients. Measurements and Main Data on nutrition practices were collected from ICU admission to ICU discharge for a maximum of 12 days. Eligible sites were ranked based on their performance on the following 5 criteria: adequacy of provision of energy, use of enteral nutrition (EN), early initiation of EN, use of promotility drugs and small bowel feeding tubes, and adequate glycemic control. Of the 179 participating ICUs, 81 qualified for the BOB award. Overall, the average nutrition adequacy across sites was 56.2% (site range, 20.3%-90.1%). The top 10 performers were identified and publicly recognized. Regression analysis suggested that the presence of a dietitian in the ICU was associated with a high BOB award ranking, whereas being located in the United States or China, relative to other participating countries, was associated with worst performance. There is variable performance with respect to critical care nutrition practices across the world.Journal of Parenteral and Enteral Nutrition 34(6):707-15. · 3.29 Impact Factor -
Article: When early enteral feeding is not possible in critically ill patients: results of a multicenter observational study.
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ABSTRACT: Early enteral nutrition (EN) is the preferred strategy for feeding the critically ill; however, it is not always possible to initiate EN within the recommended 24 to 48 hours. When these situations arise, controversy exists whether to start feeding early via the parenteral route or to delay feeding until EN can be provided. A multicenter, international, observational study examined nutrition practices in intensive care units (ICUs). Eligible patients were critically ill patients with a medical diagnosis who remained in the ICU for >72 hours and received EN >48 hours after admission. Data were collected on site, including patient characteristics, daily nutrition practices, and outcomes at 60 days. Nutrition and clinical outcomes were compared between 3 groups of patients: (1) early parenteral nutrition (PN) (<48 hours after admission) and late EN (>48 hours after admission), (2) late PN and late EN, and (3) late EN and no PN. Of the 703 patients who met our inclusion criteria, 541 (77.0%) medical patients received late EN and no PN. In patients receiving late EN and PN, 83 (11.8%) received early PN and 79 (11.2%) received late PN. Adequacy of calories and protein from total nutrition was highest in the early PN group (74.1% ± 21.2% and 71.5% ± 24.9%, respectively) and lowest in the late EN group (42.9% ± 21.2% and 38.7% ± 21.6%) (P < .001). The proportion of patients dead or remaining in hospital was significantly higher for early PN compared with late EN and PN (unadjusted hazard ratio for early PN = 0.55; 95% confidence interval, 0.37-0.83, P = .015). However, this difference did not remain significant (P = .65) after adjustment for baseline characteristics. The results suggest that initiating PN early, when it is not possible to feed enterally early, may improve provision of calories and protein but is not associated with better clinical outcomes compared with late EN or PN.Journal of Parenteral and Enteral Nutrition 35(2):160-8. · 3.29 Impact Factor -
Article: The relationship between organizational culture and implementation of clinical practice guidelines: a narrative review.
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ABSTRACT: The context in which critical care providers work has been shown to be associated with adherence to recommendations of clinical practice guidelines (CPGs). Consideration of contextual factors such as organizational culture may therefore be important when implementing guidelines. Organizational culture has been defined simply as "how things are around here" and encompasses leadership, communication, teamwork, conflict resolution, and other domains. This narrative review highlights the results of recent quantitative and qualitative studies, including studies on adherence to nutrition guidelines in the critical care setting, which demonstrate that elements of organizational culture, such as leadership support, interprofessional collaboration, and shared beliefs about the utility of guidelines, influence adherence to guideline recommendations. Outside nutrition therapy, there is emerging evidence that strategies focusing on organizational change (eg, revision of professional roles, interdisciplinary teams, integrated care delivery, computer systems, and continuous quality improvement) can favorably influence professional performance and patient outcomes. Consequently, future interventions aimed at implementing nutrition guidelines should aim to measure and take into account organizational culture, in addition to considering the characteristics of the patient, provider, and guideline. Further high quality, multimethod studies are required to improve our understanding of how culture influences guideline implementation, and which organizational change strategies might be most effective in optimizing nutrition therapy.Journal of Parenteral and Enteral Nutrition 34(6):669-74. · 3.29 Impact Factor -
Article: The value of audit and feedback reports in improving nutrition therapy in the intensive care unit: a multicenter observational study.
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ABSTRACT: The objective of this study was to determine whether auditing practice and providing feedback in the form of benchmarked site reports is an effective strategy to improve adherence to nutrition guidelines. The authors conducted a multicenter observational study in Canadian intensive care units (ICUs). In January 2007, an audit of daily nutrition information was collected (type and amount of nutrition received and strategies to improve nutrition delivery). Each ICU was e-mailed individualized benchmarked performance reports documenting their performance compared with the Canadian Critical Care Nutrition guidelines and in relation to the other ICUs. Nutrition practice was reaudited in May 2008 to evaluate changes in practice. Twenty-six ICUs in Canada participated, with 473 and 486 patients accrued in 2007 and 2008, respectively. The authors observed a significant increase in enteral nutrition (EN) adequacy (from 45.1% to 51.9% for calories, and from 44.8% to 51.5% for protein) and an increase in the percentage of patients receiving EN without parenteral nutrition (from 71.9% to 81.3%). They also observed trends toward improvements in the percentage of patients who had EN started within 48 hours (from 60.3% to 66.8%). There were no significant differences in the use of motility agents or small bowel feeding in patients who had high gastric residual volumes. Audit and feedback reports are associated with improvement in some nutrition practices in many ICUs; however, the magnitude of these effects is quite modest. More research is needed to determine the optimal methods of using audit and feedback to improve quality of nutrition care.Journal of Parenteral and Enteral Nutrition 34(6):660-8. · 3.29 Impact Factor
Top co-authors
Top Journals
Institutions
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2012
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Gold Coast Hospital
Southport, Queensland, Australia
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2009–2012
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Queen's University
- Department of Medicine
Kingston, Ontario, Canada
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2011
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University of Vermont
- Department of Medicine
Burlington, VT, USA
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