Brian H Cuthbertson

Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada

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Publications (127)752.08 Total impact

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    ABSTRACT: Patients with the acute respiratory distress syndrome (ARDS) require artificial ventilation but this treatment may produce secondary lung damage. High-frequency oscillatory ventilation (HFOV) may reduce this damage. To determine the clinical benefit and cost-effectiveness of HFOV in patients with ARDS compared with standard mechanical ventilation. A parallel, randomised, unblinded clinical trial. UK intensive care units. Mechanically ventilated patients with a partial pressure of oxygen in arterial blood/fractional concentration of inspired oxygen (P : F) ratio of 26.7 kPa (200 mmHg) or less and an expected duration of ventilation of at least 2 days at recruitment. Treatment arm HFOV using a Novalung R100(®) ventilator (Metran Co. Ltd, Saitama, Japan) ventilator until the start of weaning. Control arm Conventional mechanical ventilation using the devices available in the participating centres. The primary clinical outcome was all-cause mortality at 30 days after randomisation. The primary health economic outcome was the cost per quality-adjusted life-year (QALY) gained. One hundred and sixty-six of 398 patients (41.7%) randomised to the HFOV group and 163 of 397 patients (41.1%) randomised to the conventional mechanical ventilation group died within 30 days of randomisation (p = 0.85), for an absolute difference of 0.6% [95% confidence interval (CI) -6.1% to 7.5%]. After adjustment for study centre, sex, Acute Physiology and Chronic Health Evaluation II score, and the initial P : F ratio, the odds ratio for survival in the conventional ventilation group was 1.03 (95% CI 0.75 to 1.40; p = 0.87 logistic regression). Survival analysis showed no difference in the probability of survival up to 12 months after randomisation. The average QALY at 1 year in the HFOV group was 0.302 compared to 0.246. This gives an incremental cost-effectiveness ratio (ICER) for the cost to society per QALY of £88,790 and an ICER for the cost to the NHS per QALY of £78,260. The use of HFOV had no effect on 30-day mortality in adult patients undergoing mechanical ventilation for ARDS and no economic advantage. We suggest that further research into avoiding ventilator-induced lung injury should concentrate on ventilatory strategies other than HFOV. Current Controlled Trials ISRCTN10416500. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 23. See the NIHR Journals Library website for further project information.
    03/2015; 19(23):1-178. DOI:10.3310/hta19230
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  • K Douglas, G S Hillis, B L Croal, P Gibson, B H Cuthbertson
    BJA British Journal of Anaesthesia 11/2014; 113(5):884-5. DOI:10.1093/bja/aeu354 · 4.35 Impact Factor
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    ABSTRACT: Purpose Selective Decontamination of the Digestive tract (SDD) as a prophylactic intervention improves hospital-acquired infection and survival rates. Uptake of SDD is low and remains controversial. This study applied the Theoretical Domains Framework (TDF) to assess ICU clinicians’ views about SDD in regions with limited or no adoption of SDD. Materials and Methods Participants were health professionals with ‘decisional authority’ for the adoption of SDD. Semi-structured interviews were conducted as the first round of a Delphi study. Views about SDD adoption, delivery and further SDD research were explored. Directed content analysis of interview data identified sub-themes which informed item development for subsequent Delphi rounds. Linguistic features of interview data were also explored. Results 141 participants provided interview data. Fifty-six sub-themes were identified; 46 were common across regions. Beliefs about consequences was the most widely elaborated theme. Linguistic features of how participants discussed SDD included caution expressed when discussing the risks and benefits and words such as worry, anxiety and fear when discussing potential antibiotic resistance associated with SDD. Conclusions We identified salient beliefs, barriers and facilitators to SDD adoption and delivery. What participants said about SDD and the way in which they said it demonstrated the degree of clinical caution, uncertainty and concern that SDD evokes.
    Journal of critical care 08/2014; 29(4). DOI:10.1016/j.jcrc.2014.03.013 · 2.19 Impact Factor
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    J. de Waele, J. Lipman, Y. Sakr, J. C. Marshall, P. Vanhems, C. Barrera Groba, M. Leone, J. L. Vincent, A. Margarit, R. Valentini, [...], D. Paciel, H. Bagnulo, F. Hitta, P. Nadales, H. Albornoz, Z. Salmen, C. Pacheco, T. Bui, F. Potie, C. N. Huu
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    ABSTRACT: Background: Abdominal infections are frequent causes of sepsis and septic shock in the intensive care unit (ICU) and are associated with adverse outcomes. We analyzed the characteristics, treatments and outcome of ICU patients with abdominal infections using data extracted from a one-day point prevalence study, the Extended Prevalence of Infection in the ICU (EPIC) II. Methods: EPIC II included 13,796 adult patients from 1,265 ICUs in 75 countries. Infection was defined using the International Sepsis Forum criteria. Microbiological analyses were performed locally. Participating ICUs provided patient follow-up until hospital discharge or for 60 days. Results: Of the 7,087 infected patients, 1,392 (19.6%) had an abdominal infection on the study day (60% male, mean age 62 +/- 16 years, SAPS II score 39 +/- 16, SOFA score 7.6 +/- 4.6). Microbiological cultures were positive in 931 (67%) patients, most commonly Gram-negative bacteria (48.0%). Antibiotics were administered to 1366 (98.1%) patients. Patients who had been in the ICU for <= 2 days prior to the study day had more Escherichia coli, methicillin-sensitive Staphylococcus aureus and anaerobic isolates, and fewer enterococci than patients who had been in the ICU longer. ICU and hospital mortality rates were 29.4% and 36.3%, respectively. ICU mortality was higher in patients with abdominal infections than in those with other infections (29.4% vs. 24.4%, p < 0.001). In multivariable analysis, hematological malignancy, mechanical ventilation, cirrhosis, need for renal replacement therapy and SAPS II score were independently associated with increased mortality. Conclusions: The characteristics, microbiology and antibiotic treatment of abdominal infections in critically ill patients are diverse. Mortality in patients with isolated abdominal infections was higher than in those who had other infections.
    BMC Infectious Diseases 07/2014; 14(1):420. DOI:10.1186/1471-2334-14-420 · 2.56 Impact Factor
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    ABSTRACT: Evidence supporting selective decontamination of the digestive tract (SDD) is reasonably strong. We set out to determine use in UK critical care units and to compare patient outcomes between units that do and those that do not use SDD. A total of 250 UK general critical care units were surveyed. Case mix, outcomes, and lengths of stay for admissions to SDD units (with and without an i.v. component) and non-SDD units were compared using data from the Intensive Care National Audit & Research Centre Case Mix Programme database. A response was received from all the 250 critical care units surveyed. Of these, 13 (5.2%) reported using SDD on some or all admissions, and of these, 3 reported using an i.v. component. Data on 284 690 admissions (April 2008-March 2011) from units reporting to the ICNARC Case Mix Programme (CMP) were included in the analyses. Admissions to SDD (n=196) and non-SDD (n=9) units were a similar case mix with similar infection rates and average lengths of stay in the unit and hospital. There was no difference in risk-adjusted unit or hospital mortality. The rate of unit-acquired infections in blood was significantly lower in SDD units using an i.v. component. Use of SDD in UK critical care is very low. The rate of unit-acquired infections in blood was significantly lower in SDD units using an i.v. component, but did not translate into a difference in acute hospital mortality or length of stay. There is a need to better understand the barriers to adoption of SDD into clinical practice and such work is underway.
    BJA British Journal of Anaesthesia 05/2014; 113(4). DOI:10.1093/bja/aeu108 · 4.35 Impact Factor
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    ABSTRACT: Hospital-acquired infections (HAIs) are a major cause of morbidity and mortality. Critically ill patients in intensive care units (ICUs) are particularly susceptible to these infections. One intervention that has gained much attention in reducing HAIs is selective decontamination of the digestive tract (SDD). SDD involves the application of topical non-absorbable antibiotics to the oropharynx and stomach and a short course of intravenous (i.v.) antibiotics. SDD may reduce infections and improve mortality, but has not been widely adopted in the UK or internationally. Hence, there is a need to identify the reasons for low uptake and whether or not further clinical research is needed before wider implementation would be considered appropriate. The project objectives were to (1) identify and describe the SDD intervention, (2) identify views about the evidence base, (3) identify acceptability of further research and (4) identify feasibility of further randomised controlled trials (RCTs). A four-stage approach involving (1) case studies of two ICUs in which SDD is delivered including observations, interviews and documentary analysis, (2) a three-round Delphi study for in-depth investigation of clinicians' views, including semi-structured interviews and two iterations of questionnaires with structured feedback, (3) a nationwide online survey of consultants in intensive care medicine and clinical microbiology and (4) semistructured interviews with international clinical triallists to identify the feasibility of further research. Case studies were set in two UK ICUs. Other stages of this research were conducted by telephone and online with NHS staff working in ICUs. (1) Staff involved in SDD adoption or delivery in two UK ICUs, (2) ICU experts (intensive care consultants, clinical microbiologists, hospital pharmacists and ICU clinical leads), (3) all intensive care consultants and clinical microbiologists in the UK with responsibility for patients in ICUs were invited and (4) international triallists, selected from their research profiles in intensive care, clinical trials and/or implementation trials. SDD involves the application of topical non-absorbable antibiotics to the oropharynx and stomach and a short course of i.v. antibiotics. Levels of support for, or opposition to, SDD in UK ICUs; views about the SDD evidence base and about barriers to implementation; and feasibility of further SDD research (e.g. likely participation rates). (1) The two case studies identified complexity in the interplay of clinical and behavioural components of SDD, involving multiple staff. However, from the perspective of individual staff, delivery of SDD was regarded as simple and straightforward. (2) The Delphi study (n = 42) identified (a) specific barriers to SDD implementation, (b) uncertainty about the evidence base and (c) bimodal distributions for key variables, e.g. support for, or opposition to, SDD. (3) The national survey (n = 468) identified uncertainty about the effect of SDD on antimicrobial resistance, infection rates, mortality and cost-effectiveness. Most participants would participate in further SDD research. (4) The triallist interviews (n = 10) focused largely on the substantial challenges of conducting a large, multinational clinical effectiveness trial. There was considerable uncertainty about possible benefits and harms of SDD. Further large-scale clinical effectiveness trials of SDD in ICUs may be required to address these uncertainties, especially relating to antimicrobial resistance. There was a general willingness to participate in a future effectiveness RCT of SDD. However, support was not unanimous. Future research should address the barriers to acceptance and participation in any trial. There was some, but a low level of, interest in adoption of SDD, or studies to encourage implementation of SDD into practice. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 25. See the NIHR Journals Library website for further project information.
    04/2014; 18(25):1-170. DOI:10.3310/hta18250
  • Damon C Scales, Brian H Cuthbertson
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    ABSTRACT: Percutaneous dilatational tracheostomies have become one of the most frequently performed surgical procedures in the ICU, and are believed to offer a variety of advantages over open tracheostomies, including increased convenience. Recent publications have established that the risk of fatal complications related to the procedure is low. However, clinicians must still weigh these risks against expected but largely unproven benefits. More research is needed to establish the indications for the procedure, including the optimal patient selection and timing during a course of mechanical ventilation. Such studies should also seek to improve our ability to accurately identify which patients will require prolonged mechanical ventilation, and to quantify the potential benefits of tracheostomy compared with prolonged translaryngeal intubation.
    Critical care (London, England) 03/2014; 18(2):117. DOI:10.1186/cc13761
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    ABSTRACT: Background: Bloodstream infections resulting from intravascular catheters (catheter-BSI) in critical care increase patients’ length of stay, morbidity and mortality, and the management of these infections and their complications has been estimated to cost the NHS annually £19.1–36.2M. Catheter-BSI are thought to be largely preventable using educational interventions, but guidance as to which types of intervention might be most clinically effective is lacking. Objective: To assess the effectiveness and cost-effectiveness of educational interventions for preventing catheter-BSI in critical care units in England. Data sources: Sixteen electronic bibliographic databases – including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, Cumulative Index to Nursing and Allied Health Literature (CINAHL), NHS Economic Evaluation Database (NHS EED), EMBASE and The Cochrane Library databases – were searched from database inception to February 2011, with searches updated in March 2012. Bibliographies of systematic reviews and related papers were screened and experts contacted to identify any additional references. Review methods: References were screened independently by two reviewers using a priori selection criteria. A descriptive map was created to summarise the characteristics of relevant studies. Further selection criteria developed in consultation with the project Advisory Group were used to prioritise a subset of studies relevant to NHS practice and policy for systematic review. A decision-analytic economic model was developed to investigate the cost-effectiveness of educational interventions for preventing catheter-BSI. Results: Seventy-four studies were included in the descriptive map, of which 24 were prioritised for systematic review. Studies have predominantly been conducted in the USA, using single-cohort before-and-after study designs. Diverse types of educational intervention appear effective at reducing the incidence density of catheter-BSI (risk ratios statistically significantly < 1.0), but single lectures were not effective. The economic model showed that implementing an educational intervention in critical care units in England would be cost-effective and potentially cost-saving, with incremental cost-effectiveness ratios under worst-case sensitivity analyses of < £5000/quality-adjusted life-year. Limitations: Low-quality primary studies cannot definitively prove that the planned interventions were responsible for observed changes in catheter-BSI incidence. Poor reporting gave unclear estimates of risk of bias. Some model parameters were sourced from other locations owing to a lack of UK data. Conclusions: Our results suggest that it would be cost-effective and may be cost-saving for the NHS to implement educational interventions in critical care units. However, more robust primary studies are needed to exclude the possible influence of secular trends on observed reductions in catheter-BSI.
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    ABSTRACT: Bloodstream infections resulting from intravascular catheters (catheter-BSI) in critical care increase patients' length of stay, morbidity and mortality, and the management of these infections and their complications has been estimated to cost the NHS annually £19.1-36.2M. Catheter-BSI are thought to be largely preventable using educational interventions, but guidance as to which types of intervention might be most clinically effective is lacking. To assess the effectiveness and cost-effectiveness of educational interventions for preventing catheter-BSI in critical care units in England. Sixteen electronic bibliographic databases - including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, Cumulative Index to Nursing and Allied Health Literature (CINAHL), NHS Economic Evaluation Database (NHS EED), EMBASE and The Cochrane Library databases - were searched from database inception to February 2011, with searches updated in March 2012. Bibliographies of systematic reviews and related papers were screened and experts contacted to identify any additional references. References were screened independently by two reviewers using a priori selection criteria. A descriptive map was created to summarise the characteristics of relevant studies. Further selection criteria developed in consultation with the project Advisory Group were used to prioritise a subset of studies relevant to NHS practice and policy for systematic review. A decision-analytic economic model was developed to investigate the cost-effectiveness of educational interventions for preventing catheter-BSI. Seventy-four studies were included in the descriptive map, of which 24 were prioritised for systematic review. Studies have predominantly been conducted in the USA, using single-cohort before-and-after study designs. Diverse types of educational intervention appear effective at reducing the incidence density of catheter-BSI (risk ratios statistically significantly < 1.0), but single lectures were not effective. The economic model showed that implementing an educational intervention in critical care units in England would be cost-effective and potentially cost-saving, with incremental cost-effectiveness ratios under worst-case sensitivity analyses of < £5000/quality-adjusted life-year. Low-quality primary studies cannot definitively prove that the planned interventions were responsible for observed changes in catheter-BSI incidence. Poor reporting gave unclear estimates of risk of bias. Some model parameters were sourced from other locations owing to a lack of UK data. Our results suggest that it would be cost-effective and may be cost-saving for the NHS to implement educational interventions in critical care units. However, more robust primary studies are needed to exclude the possible influence of secular trends on observed reductions in catheter-BSI. The study is registered with PROSPERO as CRD42012001840. The National Institute for Health Research Health Technology Assessment programme.
    02/2014; 18(15):1-365. DOI:10.3310/hta18150
  • Brian H Cuthbertson, Jill Francis
    Critical care (London, England) 01/2014; 18(2):417.
  • Tom W. Reader, Brian H. Cuthbertson
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    ABSTRACT: Effective multidisciplinary teamwork and team leadership have been shown as essential for the safe management of patients in intensive care medicine (ICM). Solutions to improve teamwork and leadership have been developed, but with mixed success. It is observed that to improve teamwork in ICM, interventions must reflect (1) the demands and constraints of ICM, and how they influence team behaviour and (2) the specific teamwork skills and behaviours that are associated with safe patient care. Research in ICM shows that effective team leadership is the key determinant of team functioning, and that interventions should focus on enhancing leadership. Yet, simply applying leadership solutions developed in other domains (e.g. aviation) is not appropriate. Specifically, the flow and nature of work, and the changeable and complex construction of teams, means that tools for improving and assessing leadership need to be designed to reflect the very specific constraints of ICM.
    The Organization of Critical Care, 01/2014: pages 127-135;
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    ABSTRACT: To describe factors senior critical care nurses identify as being important to address when introducing selective digestive tract decontamination (SDD) in the clinical setting. Critically ill patients are at risk of developing ventilator-associated pneumonia (VAP). SDD is one strategy shown to prevent VAP and possibly improve survival in the critically ill. We performed a secondary analysis of qualitative data obtained from 20 interviews. An inductive thematic analysis approach was applied to data obtained from senior critical care nurses during phase two of a multi-methods study. There were four primary considerations identified that should be addressed or considered prior to implementation of SDD. These considerations included education of health care professionals, patient comfort, compatibility of SDD with existing practices, and cost. Despite a lack of experience with, or knowledge of SDD, nurses were able to articulate factors that may influence its implementation and delivery. Organizations or researchers considering implementation of SDD should include nurses as key members of the implementation team.
    Heart & lung: the journal of critical care 11/2013; DOI:10.1016/j.hrtlng.2013.09.002 · 1.32 Impact Factor
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    ABSTRACT: Selective decontamination of the digestive tract (SDD) is a prophylactic antibiotic regimen that is not widely used in practice. We aimed to describe the opinions of key 'stakeholders' about the validity of the existing evidence base, likely consequences of implementation, relative importance of their opinions in influencing overall practice, likely barriers to implementation and perceptions of the requirement for further research to inform the decision about whether to embark on a further large randomised controlled trial. This was a Delphi study informed by comprehensive framework of possible determinants of health professionals' behaviour to study Critical Care practice in four countries. There were four key stakeholder participant groups including ICU physicians, pharmacists, clinical leads, and clinical microbiologists/ infectious disease physicians. Round one comprised participant interviews and Rounds two and three were online questionnaires using Delphi method. In this study, 141 participants were recruited of whom 82% were retained. Participants rated themselves as knowledgeable about SDD. Antibiotic resistance was identified as the most important issue. SDD was seen as a low clinical priority but few participants reported strong opposition. There was moderate agreement that research to date has not adequately addressed concerns about antibiotic resistance and lacks generalizability. Participants indicated equipoise with regard to benefits and harms of SDD, and indicated strong support for a further randomised trial. Clinicians have clinical equipoise about the effectiveness of SDD. Future research requires longer follow up to assess antibiotic resistance as well as greater validity/generalizability to provide definitive answers on the effectiveness of decontamination and effects on antibiotic resistance. SDD was regarded as not being a high clinical priority, which may limit future trial participation. These results have identified that a further large randomised controlled trial of SDD in critical care is both warranted and appropriate.
    Critical care (London, England) 11/2013; 17(6):R266. DOI:10.1186/cc13096
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    ABSTRACT: BACKGROUND: This study sought to identify and describe the clinical and behavioural components (e.g. the what, how, when, where and by whom) of 'selective decontamination of the digestive tract' (SDD) as routinely implemented in the care of critically ill patients. METHODS: Multi-methods study, consisting of semi-structured observations of SDD delivery, interviews with clinicians and documentary analysis, conducted in two ICUs in the UK that routinely deliver SDD. Data were analysed within-site to describe clinical and behavioural SDD components and synthesised across-sites to describe SDD in context. RESULTS: SDD delivery involved multiple behaviours extending beyond administration of its clinical components. Not all behaviours were specified in relevant clinical documentation. Overall, SDD implementation and delivery included: adoption (i.e. whether to implement SDD), operationalisation (i.e. implementing SDD into practice), provision (i.e. delivery of SDD) and surveillance (i.e. monitoring the ecological effects). Implementation involved organisational, team and individual-level behaviours. Delivery was perceived as easy by individual staff, but displayed features of complexity (including multiple interrelated behaviours, staff and contexts). CONCLUSIONS: This study is the first to formally outline the full spectrum of clinical and behavioural aspects of SDD. It identified points in the delivery process where complex behaviours occur and outlined how SDD can be interpreted and applied variably in practice. This comprehensive specification allows greater understanding of how this intervention could be implemented in units not currently using it, or replicated in research studies. It also identified strategies required to adopt SDD and to standardise its implementation.
    Australian Critical Care 11/2013; 26(4). DOI:10.1016/j.aucc.2013.04.002 · 1.27 Impact Factor
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    ABSTRACT: Behaviour change interventions often target 'important' beliefs. The literature proposes four methods for assessing importance of attitudinal beliefs: elicitation frequency, importance ratings, and strength of prediction (bivariate and multivariate). We tested congruence between these methods in a Delphi study about selective decontamination of the digestive tract (SDD). SDD improves infection rates among critically ill patients, yet uptake in intensive care units is low internationally. A Delphi study involved three iterations ('rounds'). Participants were 105 intensive care clinicians in the United Kingdom, Canada, and Australia/New Zealand. In Round 1, semi-structured interviews were conducted to elicit beliefs about delivering SDD. In Rounds 2 and 3, participants completed questionnaires, rating agreement and importance for each belief-statement (9-point Likert scales). Belief importance was assessed using elicitation frequency, mean importance ratings, and prediction of global attitude (Pearson's correlations; beta-weights). Correlations between indices were computed. Participants generated 14 attitudinal beliefs. Indices had adequate variation (frequencies: 4-94, mean importance ratings: 4.93-8.00, Pearson's correlations: ±0.09 to ±0.54, beta-weights: ±0.01 to ±0.30). SDD increases antibiotic resistance was the most important belief according to three methods and was ranked second by beta-weights (behind Overall, SDD benefits patients to whom it is delivered). Spearman's correlations were significant for importance ratings with frequencies and correlations. However, other indices were unrelated. The top four beliefs differed according to the measure used. Results provided evidence of congruence across three methods for assessing belief importance. Beta-weights were unrelated to other indices, suggesting that they may not be appropriate as the sole method. What is already known on this subject? Attitudinal beliefs (specific beliefs about the consequences of performing an action) are key to designing interventions to change intentions and behaviour. The literature reports four methods for assessing the importance of attitudinal beliefs: frequency of elicitation in interviews, importance ratings in questionnaires, and strength of prediction (bivariate and multivariate) of global attitude scores. The congruence between these measures of importance is not known. What does this study add? Four indices of importance were examined in a multi-professional, international study about the use of selective digestive decontamination to prevent infection in intensive care settings. Three indices were correlated with one another. Each method used to assess importance produced a different subset of the most important beliefs. Selection of the most important beliefs should use multiple assessment methods. This evidence suggests that multiple regression approaches may not be appropriate as the sole method for assessing belief importance.
    British Journal of Health Psychology 09/2013; 19(2). DOI:10.1111/bjhp.12066 · 2.70 Impact Factor
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    ABSTRACT: There is increasing interest in evidence-based educational interventions in central venous catheter care. It is unclear how effective these are at reducing the risk of bloodstream infections from the use of intravascular catheters (catheter-BSIs) and the associated costs and health benefits. To estimate the additional costs and health benefits from introducing such interventions and the costs associated with catheter-BSIs. A comprehensive epidemiological and economic review was performed to develop the parameters for an economic model to assess the cost-effectiveness of introducing an educational intervention compared with clinical practice without the intervention. The model follows the clinical pathway of cohorts of patients from their admission to an intensive care unit (ICU), where some may acquire catheter-BSI, and estimates the associated costs, mortality and life expectancy. The additional cost per catheter-BSI episode was £3940. The results of this model demonstrate that introducing an additional educational intervention to prevent catheter-BSI improved patient life expectancy and reduced overall costs. Introducing evidence-based education is likely to reduce the incidence of catheter-BSI and the model results suggest that the cost of introducing the interventions will be outweighed by savings related to reduced ICU bed occupancy costs.
    The Journal of hospital infection 09/2013; 86(1). DOI:10.1016/j.jhin.2013.09.004 · 2.78 Impact Factor
  • Nick Daneman, Syed Sarwar, Robert A Fowler, Brian H Cuthbertson
    The Lancet Infectious Diseases 09/2013; 13(9):737-8. DOI:10.1016/S1473-3099(13)70219-6 · 19.45 Impact Factor
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    ABSTRACT: Introduction The socio-economic impact of critical illnesses on patients and their families in Europe has yet to be determined. The aim of this exploratory study was to estimate changes in family circumstances, social and economic stability, care requirements and access to health services for patients during their first 12 months after ICU discharge. Methods Multi-center questionnaire-based study of survivors of critical illness at 6 and 12 months after ICU discharge. Results Data for 293 consenting patients who spent greater than 48 hours in one of 22 UK ICUs were obtained at 6 and 12 months post-ICU discharge. There was little evidence of a change in accommodation or relationship status between pre-admission and 12 months following discharge from an ICU. A negative impact on family income was reported by 33% of all patients at 6 months and 28% at 12 months. There was nearly a 50% reduction in the number of patients who reported employment as their sole source of income at 12 months (19% to 11%) compared with pre-admission. One quarter of patients reported themselves in need of care assistance at 6 months and 22% at 12 months. The majority of care was provided by family members (80% and 78%, respectively), for half of whom there was a negative impact on employment. Amongst all patients receiving care, 26% reported requiring greater than 50 hours a week. Following discharge, 79% of patients reported attending their primary care physician and 44% had seen a community nurse. Mobility problems nearly doubled between pre-admission and 6 months (32% to 64%). Furthermore, 73% reported moderate or severe pain at 12 months and 44% remained significantly anxious or depressed. Conclusions Survivors of critical illness in the UK face a negative impact on employment and commonly have a care requirement after discharge from hospital. This has a corresponding negative impact on family income. The majority of the care required is provided by family members. This effect was apparent by 6 months and had not materially improved by 12 months. This exploratory study has identified the potential for a significant socio-economic burden following critical illness.
    Critical care (London, England) 05/2013; 17(3):R100. DOI:10.1186/cc12745
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    ABSTRACT: Importance Tracheostomy is a widely used intervention in adult critical care units. There is little evidence to guide clinicians regarding the optimal timing for this procedure. Objective To test whether early vs late tracheostomy would be associated with lower mortality in adult patients requiring mechanical ventilation in critical care units. Design and Setting An open multicentered randomized clinical trial conducted between 2004 and 2011 involving 70 adult general and 2 cardiothoracic critical care units in 13 university and 59 nonuniversity hospitals in the United Kingdom. Participants Of 1032 eligible patients, 909 adult patients breathing with the aid of mechanical ventilation for less than 4 days and identified by the treating physician as likely to require at least 7 more days of mechanical ventilation. Interventions Patients were randomized 1: 1 to early tracheostomy (within 4 days) or late tracheostomy (after 10 days if still indicated). Main Outcomes and Measures The primary outcome measure was 30-day mortality and the analysis was by intention to treat. Results Of the 455 patients assigned to early tracheostomy, 91.9% (95% CI, 89.0%-94.1%) received a tracheostomy and of 454 assigned to late tracheostomy, 44.9% (95% CI, 40.4%-49.5%) received a tracheostomy. All-cause mortality 30 days after randomization was 30.8% (95% CI, 26.7%-35.2%) in the early and 31.5% (95% CI, 27.3%-35.9%) in the late group (absolute risk reduction for early vs late, 0.7%; 95% CI, -5.4% to 6.7%). Two-year mortality was 51.0% (95% CI, 46.4%-55.6%) in the early and 53.7% (95% CI, 49.1%-58.3%) in the late group (P=.74). Median critical care unit length of stay in survivors was 13.0 days in the early and 13.1 days in the late group (P=.74). Tracheostomy-related complications were reported for 6.3% (95% CI, 4.6%-8.5%) of patients (5.5% in the early group, 7.8% in the late group). Conclusions and Relevance For patients breathing with the aid of mechanical ventilation treated in adult critical care units in the United Kingdom, tracheostomy within 4 days of critical care admission was not associated with an improvement in 30-day mortality or other important secondary outcomes. The ability of clinicians to predict which patients required extended ventilatory support was limited.
    JAMA The Journal of the American Medical Association 05/2013; 309(20-20):2121-2129. DOI:10.1097/01.sa.0000443870.68248.ea · 30.39 Impact Factor

Publication Stats

4k Citations
752.08 Total Impact Points

Institutions

  • 2009–2015
    • Sunnybrook Health Sciences Centre
      • Department of Critical Care Medicine
      Toronto, Ontario, Canada
  • 2011–2014
    • University of Toronto
      • • Department of Anesthesia
      • • Sunnybrook Health Sciences Centre
      Toronto, Ontario, Canada
    • Trillium Health Centre
      Mississauga, Ontario, Canada
  • 1997–2011
    • University of Aberdeen
      • • Health Services Research Unit
      • • Institute of Medical Sciences
      Aberdeen, Scotland, United Kingdom
  • 2005–2006
    • University of Southampton
      • Southampton Health Technology Assessments Centre
      Southampton, ENG, United Kingdom
  • 1999
    • Royal North Shore Hospital
      Sydney, New South Wales, Australia