key: cord-0007056-3eq19uli
authors: nan
title: Critical Care Canada Forum 2018 Abstracts
date: 2019-01-14
journal: Can J Anaesth
DOI: 10.1007/s12630-019-01292-0
sha: 139c487622fbfbae7b27d6a9438e8c24f23420ab
doc_id: 7056
cord_uid: 3eq19uli

nan

The change ideas hypothesized to have the greatest impact on E-R were not successfully rolled out. A better understanding of the distribution of the root cause to extubation delay may have resulted in more focused interventions. Additionally, the use of Spontaneous Breathing Trials as readiness to extubate criteria may not be appropriate for all subset of patients. Future work should center on standardization of extubation criteria.

In 2016, the Critical Care Societies Collaborative published a Call to Action in an effort to bring attention to an alarmingly high level of burnout in critical care health providers. 1 Burnout syndrome develops as a result of chronically high levels of stress in the workplace and is characterized by emotional exhaustion, depersonalization and reduced personal accomplishment 2 . Burnout has a significant impact on healthcare providers 3,4 the patients whom they care 5,6 for and the system in which they work 3, 7 .

Objective: The purpose of this survey was to identify the rates of burnout and workplace factors that may be contributing to burnout among nurses, respiratory therapists and physicians who work in the ICUs in the Department of Critical Table 2 shows the scores by profession. 37.6% of respondents scored high for burnout in 1 domain, 10 .9% scored high in two domains and 4.8% scored high in all three domains. Logistic regression showed that a longer duration of critical care work experience was associated with a lower level of emotional exhaustion and depersonalization. Pediatric healthcare providers had a lower rate of emotional exhaustion compared to adults, but no difference in depersonalization or professional accomplishment. There was no statistic difference between academic vs community centers in any domain. Analysis of the Areas of Worklife Survey showed a very strong association between five of the six subscales (workload, control, reward, fairness and values) and two of the three burnout domains (emotional exhaustion and depersonalization). 55.2% of participants reported moral distress at least a few times a month and 29.9% reported it at least once a week. Conclusions: Burnout and moral distress is a significant issue for nurses, respiratory therapists and physicians who work in the ICUs in the Department of Critical Care, Halifax, Nova Scotia. This knowledge will help provide direction for management and support for our critical care healthcare providers moving forward. (14) Introduction: Raised intracerebral pressure (ICP) in the setting of traumatic brain injury (TBI) is a common problem and associated with worsening neurological outcomes. Previous systematic reviews have failed to demonstrate a survival advantage of mannitol over hypertonic saline in the management of ICP in TBI patients. However, there are no published systematic reviews comparing the magnitude and temporal durability in the reduction of ICP between the various concentrations of mannitol and hypertonic saline (HTS). Objectives: To determine the temporal reduction in ICP using mannitol, HTS and to compare the efficacy of ICP reduction between the two agents and the effects of varying volumes and concentrations. Methods: The review followed the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) as the following databases were searched: PubMed (1947 to July 2016), EMBASE (1947 to July 2016), Medline, Cochrane Databases of Systematic Review and Web of Science. The key phrases used in the search were: hypertonic saline, sodium chloride, osmotic diuretic, mannitol, intracranial pressure, traumatic brain injury, head injury. Eligibility criteria for the study included: use of an osmotic diuretic, raised intracranial pressure, adults older than 16, traumatic brain injury. Few studies had a mixed patient population of TBI and subarachnoid hemorrhage. General estimating equations for correlated longitudinal data were used to model the temporal reduction in study averaged ICP, the effect of mannitol versus HTS, and volume and concentration of therapy. Adjustment was made for study methodology. Results: 1349 records were identified using the search strategy. Eighteen randomized controlled trials and 14 cohort studies were used in the systematic review of which 7 studies (4 randomized trials and 3 cohort studies) compared mannitol with HTS and reported mean ICP values suitable for pooled GEE analysis. Univariable ICP reductions were demonstrated at 60 minutes using HTS (p < 0.0001) and mannitol (p = 0.02) but not at 30 or 120 minutes for either treatment. In the multivariable model, a significant ICP reduction was demonstrated over time (p < 0.0001), however there was no significant difference in ICP reduction between the HTS versus the mannitol group (p = 0.92). Neither treatment volume, concentration nor their interaction were modifiers of the effect of either treatment. However, non-randomized studies did modify the treatment effect [ Table 1 ] When all available data from either single treatment (HTS or mannitol) studies or comparison studies were pooled to model the temporal reduction in ICP by individual treatment type, HTS demonstrated a more significant reduction in ICP at 30 (p=0.002), 60 (p<0.0001) and 120 min (p=0.0004) as compared to mannitol at 30 (p=0.002), 60 (p=0.004) and 120 min (p=0.03). [ Figures 1, 2] Using individual treatment models, a significant interaction was seen between the volume and concentration of HTS indicating optimal concentrations of ≤ 10% and volumes of ≤ 250 ml. Conclusion: Both mannitol and HTS are effective at reducing ICP at 30, 60, and 120 minutes after bolus dosing. Although a larger ICP reduction was demonstrated using HTS, this was not statistically significant. A significant interaction was noted between the volume and osmotic concentration using HTS indicating that increasing volumes of low concentration HTS does not result in a greater reduction of ICP. 

Grant, Jennifer M. 1 ; Porter, Chalene A. 1 ; Charles, Marthe 1 ; Bryce, Elizabeth A. 1 ; Wong Titus 1 ; Stefanovic, Aleksandra 1 ; Roscoe, Diane R. 1 1 Department of Pathology and Laboratory Medicine, Division of microbiology, Vancouver Coastal Health, Vancouver, British Columbia, Canada

Objective: There is a direct relationship between appropriate antibiotic administration and survival in patients with sepsis encouraging broad spectrum drugs, while use of narrower spectrum antibiotics reduces adverse events and development of resistance. Rapid diagnostic testing allows more timely and accurate antibiotic prescription, thus improving clinical outcomes in patients with positive blood-cultures. The AcceleratephenoTM system (AXDX) is a platform for rapid identification (ID -90 minutes) and susceptibility testing (AST -<7 hours) from positive blood culture bottles.

We assessed the potential of AXDX results to influence more timely antibiotic tailoring interventions on a convenience sample of 154 positive blood cultures from unique patients.

Blood cultures with a gram stain for a single organism likely to be on the AXDX panel were run in parallel with the standard of care (SOC) when a trained technologist and machine was available for loading. Using results from the Standard of care (SOC), Medical Microbiologists noted interventions made at the time of blood culture gram stain, organism identification and AST result availability. The timing of MM intervention was noted and compared to fastest potential time in SOC and with AXDX timing. Results: Of 154 cultures assessed by AXDX, 148 resulted in actions by either the microbiologist or medical team; 113 (76%) of which were attributable to data available from AXDX. The most common AXDX attributable intervention was narrowing of antibiotics in 76 (67%) cases, followed by escalation of therapy in 24 (21%) instances or recommending a specialist consult (5%). Compared to SOC, AXDX results were 15.8±12.6h faster to organism ID. Likewise for AST, time-saving was 28.3±11.6h. Given the time saving, it would be possible to save 34 days of broad spectrum therapy by using AXDX for more timely results. For those patients requiring broader therapy, time delay to correct therapy could be decreased by 18h on average. Conclusions: There is significant potential for results from rapid diagnostic panels such as AXDX to support timely antimicrobial prescribing and other management decisions to benefit patients. Next steps include identifying septic patients in the ICU who would benefit from timelier reporting of antimicrobial susceptibility.

Introduction: Risk-stratification of patients with suspected infection is important.

Existing prognostic tools (such as SIRS and qSOFA criteria) lack accuracy in older patients with suspected infection. Therefore, new methods for accurate outcome prognostication in older people with suspected infection are needed. Frailty, a syndrome based on accumulation of age-and disease-related deficits, is associated with vulnerability to adverse health outcomes. However, the association of frailty with adverse outcomes among older patients with suspected infection is poorly described. Introduction: Traumatic injuries are a major cause of morbidity and mortality worldwide. In trauma patients, cell and tissue death can result from inflammation or injury. Cell-free DNA (cfDNA) has anti-fibrinolytic and pro-coagulant effects and can be released by neutrophils via NETosis in response to infection, sterile inflammation, and hypoxia or by processes like necrosis. Previously, cfDNA has been noted to be elevated and prognostic in sepsis. In patients with severe traumatic brain injury, high levels of cfDNA were associated with an increased risk of death. Protein C (PC) is a natural anticoagulant that inhibits coagulation in the microcirculation. Low PC levels are associated with increased risk of death in sepsis. Objective: to determine if cfDNA or PC, previously shown to be capable of discriminating between survivors and non-survivors in sepsis, had prognostic utility in trauma patients. Methods: Patient plasma samples were obtained from a combination of two prospective observational cohort studies: DYNAMICS (NCT0135504) and ENPOLY. Clinical data and plasma samples were obtained on admission, daily for the first week, and then weekly thereafter. Levels of cfDNA, PC, and Myeloperoxidase (MPO) were measured in the plasma using established laboratory protocols. Using 293XL-hTLR9 reporter cells, we determined the levels of NF-kB activation by these cells in response to cfDNA from the ENPOLY samples at all time points. Results: A total of 77 trauma patients were included (n=38 from DYNAMICS and n=39 from ENPOLY). The median age was 49 years; 27.3% were female. Mortality was 16.9% at 28 days. Levels of cfDNA were elevated compared to healthy values in our patient population, but not significantly different between survivors and non-survivors. PC levels were reduced in our population compared to normal levels but did not differ significantly between survivors and non-survivors. Platelet count on admission was significantly lower in non-survivors than survivors (p< 0.01) suggesting an underlying consumptive process. Receiver Operating Characteristic curves for predicting mortality are shown in Table 1 . When plasma samples were added with 293XL-hTLR9 reporter cells, there was no production of SEAP at any time point, indicating no NF-kB activation and the cfDNA in trauma samples is not bacterial in origin. When MPO levels were quantified as a surrogate marker of NETosis, there was no correlation to cfDNA levels (r= -0.192, p = 0.115); however, a positive correlation existed between MPO and cfDNA in a comparison group of septic patients (n=52) from the DYNAMICS study (r=0.424, p < 0.001). Conclusion: Levels of cfDNA and PC are abnormal in multiple critical conditions such as sepsis and trauma. However, variation in the source of cfDNA between septic and trauma patients may account for differences in prognostic utility. In trauma patients, future studies into dysregulation of platelet production and function may prove useful for improving survival.

Alabdrab Background: Pulmonary embolism is a difficult diagnosis, with potentially serious consequences, but computed tomographic pulmonary angiography is also not without complications. Our hospital is a cancer and neuroscience center with high risk for pulmonary embolism, and high frequency of performing computed tomographies for it. Methods: This is a prospective observational study designed to measure all the potential complications of computed tomographic pulmonary angiographies in adults (including contrast-induced nephropathy and allergic reactions, as well as lifetime radiation related risk of cancer and cancer mortality). We then compared this to the incidence of pulmonary embolism and the frequency of its complications in the same cohort (mechanical ventilation, use of vasopressors, and hemorrhage from thrombolysis), as well as the pulmonary embolism cases that could have been missed if computed tomography was only performed for high risk patients.

We analyzed a sample of 134 consecutive patients who presented to the emergency department between March 2014 and December 2017. We found a 13.4% incidence of contrast-induced nephropathy (18/134 patients). None of them required dialysis & nobody developed allergic reactions. Lifetime risk of cancer attributable to this computed tomography exposure was estimated to increase by 0.147% & risk of death by 0.071%. The incidence of confirmed pulmonary embolism in the same sample was 20.1% (27/134 patients), 3 of them died because of pulmonary embolism (representing 11.1% from patients with confirmed pulmonary embolism). 11.2% required mechanical ventilation (15/134 patients), and 5.2% required vasopressors (7/134 patients). Only 1 patient re-quired thrombolytic therapy (0.7%). He did not develop hemorrhage after treatment. Compared to the 11.1% mortality rate of treated cases, the historical mortality rate of undiagnosed and untreated cases has been reported between 26-30%. If computed tomography was restricted to high clinical risk cases, we could have missed 55% of pulmonary embolism cases, resulting in a potential mortality increase from 11.1% to 20.2%. Conclusion: The incidence of pulmonary embolism and its complications in this patient population was higher and more serious than the incidence of computed tomography complications. Therefore, we would still recommend maintaining a low threshold of obtaining a computed tomography pulmonary angiography in this patient population. Introduction: Renal replacement therapy (RRT) is a complex and expensive form of life-sustaining therapy, reserved for our most acutely ill patients. While a number of randomized trials have evaluated the optimal timing to start RRT among critically ill patients in the ICU, there has been a paucity of trials providing guidance on when and under what circumstances to ideally liberate a patient from RRT. 1, 2, 3 Objectives: To conduct a systematic review and meta-analysis of available evidence on clinical and biochemical markers that predict renal recovery and successful liberation from acute RRT among critically ill patients with acute kidney injury (AKI). Methods: A comprehensive search strategy was developed in consultation with a research librarian and independently peer-reviewed by a second librarian. Electronic databases (Ovid Medline, Ovid Embase and Wiley Cochrane Library) were searched, as were selected grey literature sources. Our search strategy focused on concepts related to RRT (i.e., intermittent hemodialysis (IHD), slow low-efficiency dialysis (SLED), continuous renal replacement therapy (CRRT)); intensive care medicine (i.e., involving any intensive care unit (ICU) setting) and discontinuation of therapy (i.e., either clinical, physiological and biochemical parameters of weaning acute RRT). Citation screening, selection, quality assessment and data abstraction were performed in duplicate. Studies were pooled in statistical meta-analysis when deemed sufficiently clinically homogenous, with sensitivities and specificities pooled simultaneously using a hierarchical summary receiver operator characteristic curve (HSROC) and bi-variate analysis. Results: Our search yielded 3031 results, of which 20 studies fulfilled eligibility; 18 cohort studies and 2 case control studies, evaluating a total of 3650 patients ( Figure 1 ). Studies were assessed for quality and risk of bias using the Newcastle-Ottawa Score (NOS). The mean NOS score was 7 (range 4-9) and the majority of studies were of high quality (n=16, 80%) with 4 studies rated as moderate quality (20%). There were no studies identified as being poor quality. The most commonly identified parameter was urine output, identified in 9 studies (45%), followed by serum Cystatin C, which was identified in 3 studies (15%). Other identified biomarkers included kinetic eGFR, plasma NGAL, urine urea, creatinine clearance (2-and 24-hour), NT-proBNP and multivariate models including baseline parameters, each identified in a single instance. However, all identified parameters exhibited significant heterogeneity between studies. Conclusion: 20 studies were identified evaluating clinical and biochemical parameters of weaning RRT in critically ill patients with AKI. Urine output and serum cystatin C were the most commonly identified parameters, although definitions and cutoff values were heterogenous between studies. Further study is required to better define cutoffs and clarify the role of various biomarkers and elucidate accurate predictive models of RRT weaning in the critically ill patient population. Future work will involve quantitative analysis of the various identified weaning parameters. Students were given the opportunity to fill out a 10 item self-report questionnaire anonymously. Total time 150 Introduction: Diarrhea is a frequent concern in the Intensive Care Unit (ICU) and its incidence varies from 2-95%. This variation may be due to the absence of a consistent definition of diarrhea and inattention to this clinical problem.

Objectives: The objectives of this study were to describe the epidemiology of diarrhea in critically ill patients including the incidence, risk factors, and consequences of diarrhea, and the incidence of Clostridium difficile-associated diarrhea.

Methods: This prospective cohort study was undertaken over 10 weeks in 9 ICUs in Canada and the United States. We included all patients >18 years old who were admitted to the ICU for >24 hours and followed them daily until ICU discharge. The bedside nurse documented all bowel movements, classifying them using the Bristol and Bliss Stool Charts. We defined diarrhea in 3 ways: 1) WHO Criteria of >3 liquid bowel movements per day (Bristol type 7), 2) any Bristol type 6 or 7 stool, and 3) any Bliss score of 4. Daily data on pertinent life support, laboratory values (e.g., electrolytes), treatment (e.g., medications, fecal management devices, nutrition), and outcomes (including mortality) were evaluated using multivariate methods. ventilated patients. While some baseline factors increase the chance of diarrhea during critical illness (e.g., frailty, and gastrointestinal comorbidity associated with diarrhea), some potentially modifiable time-dependent factors also increase the risk (e.g., antibiotics, enteral nutrition, Clostridium difficile infection and proton pump inhibitors).

The Hamilton Early Warning Score (HEWS) is an electronic bedside tool that uses vital sign abnormalities to detect potential critical events. HEWS at ED triage had poor (AUROC 0.62) discriminative ability for predicting the likelihood of critical event during subsequent hospital stay but better discrimination for critical events in patients who are septic (AUROC 0.82). 1,2 New evidence suggests using social determinants may assist in predicting adverse events. A Danish study found that among septic ICU patients, low income was significantly associated with increased 30day mortality. 3 In 2010, McMaster University and the Hamilton Spectator collaborated on the Code Red project which described the disparities in the determinants of health and health status that exists in the City of Hamilton's neighbourhoods. 4, 5 Objectives: The primary objective of our study was to determine whether the addition of social determinants such as postal code and income level add predictive value to the current HEWS.

The study population was derived from an existing database of patients admitted to one of 8 adult medical or surgical wards at the Hamilton General and Juravinski hospitals over a 6-month period from January to June 2015. Cases experienced a critical event defined as an unplanned intensive care unit admission, cardiopulmonary resuscitation, or unexpected death. Controls were matched to cases in a 2-to-1 ratio controlling for comorbidities defined by their Charlson Comorbidity Index. To this case-control data was added the first half of the postal code and the income tertiles for these areas of Hamilton. We used the 2010 Hamilton Code Red report to define postal codes residing in higher risk areas. 4, 5 Conditional Regression was used to evaluate the correlation between HEWS at ED triage, residing in a highrisk area, and income tertiles as a predictor for critical events. Results: The cohort consisted of 798 patients 270 of whom experienced a critical event (45.1%). Chi-Square analysis identified that residing in Code Red areas (p=0.01) and an elevated HEWS at ED triage (p=0.00) as significant. Conditional regression analysis identified Code Red areas (p=0.02, RR= 1.81) and HEWS (p=0.03, RR= 1.27) but not income tertiles as predictors for critical events. Conclusion: We found that residing in a Code Red area within Hamilton placed patients admitted to a medicine or surgical ward at increased risk for a critical event.

Income level, as determined by one's postal code was not found to be a predictor for critical event. Further investigation into the utility of early warning scores should consider other social determinants such as education and housing quality as well access to a primary care physician and transportation. ANOVA was used to determine difference between experimental stages both within and between patients. Results: Ten septic patients (6 males, 4 females: age 53.3 ± 9.8 years) completed the protocol within 1-3 days of sepsis onset. Increasing PC intensity had no effect on global hemodynamics, but was associated with a dose-dependent decrease in MCAv, and an improvement in both EF and GLS. The changes in MCAv, EF, and GLS were not uniform across patients, occurring at different PC intensities in some, while not changing in others.

In contrast to healthy volunteers (Chen et al, 2017), increasing PC intensity in septic patients is associated with a dose-dependent decrease in cerebral blood flow and improvement in heart function, despite stable hemodynamics. Furthermore, the PC intensity that results in these changes varies between patients.

Our results are the first to show that in-bed PC can induce changes in distal organ function, improving heart contractility in a dose-dependent manner. However, this may come at the expense of brain perfusion. The PC intensity dose that results in these changes differs between patients, suggesting the need for its individualized prescription in individual patients. 3 . We wished to determine the potential of intra-peritoneal Ed-Mɸ delivery in a rodent polymicrobial abdominal sepsis. Methods: Directed differentiation of murine PSCs was used to produce expandable Ed-Mɸ conditioned to a 'LPM-peritoneal-like' phenotype with granulocyte-macrophage colony-stimulating factor. Polymicrobial sepsis was developed in rats by instilling cecal slurry intraperitoneally (i.p., 0.5g/kg). Ed-Mɸ (10x10^6 cells/kg) or vehicle (PBS) were given i.p. to the rats 4h later and the animals were monitored for 48 or 72 hours. Lung functional parameters, broncho-alveolar lavage (BAL), peritoneal lavage fluid (PLF) and major organs were collected for infiltration and bacterial count assessment. Macrophages (Mf) and neutrophils (Nf) were isolated from the peritoneum of septic animals using Ficoll gradient and their phagocytic function (using serum opsonized zymosan), activation state, reactive oxygen species (ROS) production, as well as Mf efferocytosis determined by confocal microscopy. Nf apoptotic markers were assessed by Western blot analysis. Results: Ed-Mɸ treatment significantly attenuated the increase in alveolar and peritoneal white blood cell and neutrophil infiltration induced following abdominal fecal sepsis. Ed-Mɸ-treated rats cleared bacteria more efficiently, with lower bacterial counts (CFU/mL in the lung, liver & spleen compared to vehicle-treated animals). Peritoneal Mɸ isolated from septic rats treated with Ed-Mɸ showed better attachment, more effective phagocytosis and higher ROS production, compared to Mɸ's from vehicle treated animals. In contrast, peritoneal Nf isolated from septic rats treated with vehicle were more active and produced more ROS than Nf isolated from septic rats treated with Ed-Mɸ. Apoptotic markers (Caspase-3 and Bax) were significantly more expressed in PLF Nf from Ed-Mɸ treated than vehicle treated septic rats 72h after sepsis induction. That indicates prolonged life span of PLF Nf from PBS-treated rats, as another sign of more severe sepsis 4 in this animal group. Conclusions: Intra-peritoneal Ed-Mf therapy attenuated the severity of fecal sepsis, and reduced bacterial load, and may have therapeutic potential for systemic sepsis. 

Conclusions: EOL learning objectives in Canada are currently most effectively taught through direct observation, informal advice, and academic-half day sessions. Residents self-report a modest level of comfort with all EOL teaching objectives except for those related to donation after cardiac death-an area which program directors also identify as requiring more effective teaching. Critical care medicine residency programs may consider implementing a comprehensive EOL curriculum including focus on these objectives. Particular attention should be devoted to organ donation to ensure these competencies are attained.

odds of hospital mortality. We did not show a significant relationship between the presence of any antibiotic resistant organism and mortality. Objective: To explore the feasibility and safety of delivering advanced medical care to patients in a simulated Ebola treatment unit. The objective of the pilot study was to develop a protocol of simulated advanced supportive care under two climatic conditions: 'hot'(35 0 C, 60% humidity); 'cool' (20 0 C, 20% humidity). Methods: Participants were healthcare workers; they received an information package and instructional videos of the study procedures and completed a pre-study medical fitness checklist. Study procedures included donning and doffing of personal protective equipment (PPE), inserting a peripheral venous catheter (PIV) and a mid-line arm venous catheter (mid-line catheter), and endotracheal intubation. Participants were assigned to either hot or cool conditions and performed tasks on mannequins. Heart rate (HR), respiratory rate (RR), skin temperature, and blood pressure (BP) monitors were attached to each participant. Weight, height, and baseline and post-simulation vital signs were measured. Task feasibility was measured using a task specific checklist, participants' task completion times, and percentages of tasks completed. Safety was assessed by vital signs measurements, number of PPE breaches, and health-concerning and near-miss incidents. Health-concerning threshold values for simulation cessation were HR >85% of maximum HR or <40 beats/minute, systolic BP <90 mmHg or a drop >40 mmHg below baseline, a self-rated thermal comfort scale of ≥12 (from 1, so cold that I am helpless to 13, so hot I am sick and nauseated), or any report of feeling unwell. Results: 14 healthcare workers participated, 3 others were excluded after a medical assessment. There were 9 physicians and 5 nurses, 50% were female. Mean (SD) age was 41 (7) 2) 0 C respectively. There were 6 health concerning-incidents in 4 participants (all allocated to the hot condition); 42 minor breaches in PPE use, with at least 1 breach in each participant; and 37 nearmiss incidents in 13 participants. We terminated the simulation of 1 participant who was nauseous and heat strained. All participants had near baseline vital signs measurements at the end of their simulation. Conclusion: For physicians, the procedural tasks appear feasible. The study team is currently developing tasks and case scenarios specifically tailored to nurses. In the full study, participants will be randomized to two temperature/humidity conditions. 

Introduction: Recently, a consensus definition for pediatric prolonged mechanical ventilation (PMV) has been proposed, including all children or infants >37 weeks gestational age (GA) ventilated invasively or non-invasively ≥ 3 wks 1 . Early tracheostomy has been shown to be associated with improved morbidity and mortality in adults, however little is known about the attitudes of physicians towards tracheostomy for pediatric PMV 2 .

Objectives: Characterize the stated practice of qualified Canadian physicians (pediatric intensivists, neonatologists, respirologists and otolaryngologists to tracheostomy, specifically for pediatric PMV.

We designed a 2-part cross-sectional, web-based survey for REDCap according to established methodology 3, 4 . Part 1 consisted of questions related to demographics while part 2 presented 3 case-based scenarios followed by a series of alterations in a single relevant clinical variable. Case 1 was a neonate with bronchopulmonary dysplasia now at 40 weeks gestational age. Cases 2 and 3 were previously healthy 1 and 10-year-olds with acute respiratory distress syndrome ventilated for 3 weeks. The Chi-square test was used to compare differences in likelihood of recommending tracheostomy at 3 weeks of MV between cases and by subspecialty. The McNemar's test was used to evaluate whether altering specific clinical variables changed physician willingness to recommend tracheostomy, and its impact on preferred timing (≤ 3 weeks or > 3 weeks of MV). Results: Overall response rate was 165/396 (42%). We received at least 1 response all 16 Canadian tertiary-care academic hospitals performing pediatric tracheostomy. Table 1 shows that 47/121 (38.8%), 23/93 (24.7%) and 40/87 (46.0%) of respondents would recommend tracheostomy at or before 3 weeks of MV for case 1, 2 and 3, at baseline respectively; the difference between case 2 and 3 was statistically significant (p < 0.001). As shown in Figure 1 only two of 16 clinical variables -subglottic stenosis (OR 6.5 95% CI 1.47-59.33), and bilateral vocal paralysis (OR 5.33, 95% CI 1.53-28.56) -significantly increased the likelihood of ever recommending tracheostomy, in case 1, and none in cases 2 and 3. Far more variables were associated with a decreased likelihood of ever recommending tracheostomy for all 3 cases , the strongest of which was with life limiting condition (Case 1, OR 0.06, 95% CI 0.02-0.17, Case 2 OR 0.03 95% CI 0.0-0.1, Case 3 OR 0.05 95% CI 0.01-0.2). The association between variables and preferred timing of tracheostomy can be seen in figure 2 . Again, in case 1 a strong association was found between recommendation for earlier tracheostomy and subglottic stenosis (OR 31 95% CI 5.7-1263.43) or bilateral vocal cord paralysis (OR 16, 95% CI 4.08-137.79). Conclusion: A significant majority of physicians appear reluctant to recommend tracheostomy for children requiring PMV. Further, there were only a small number of factors that increased the likelihood of recommending tracheostomy at ≤ 3 weeks of MV. The information obtained in this survey will help to inform a Canada-wide prospective cohort study to evaluate the effects of early tracheostomy on patient outcomes in paediatric PMV.

Introduction: Dehumanization is the process of depriving someone of positive human qualities. It is usually seen as an overt, active, extreme, conflict driven phenomenon, 1 and not typically thought of as being associated with health care. There is however a more subtle form of dehumanization called infrahumanization that can occur outside conflict situations. Infrahumanization can occur whenever groups identify others as being outside their cohort and has been shown to occur in medical settings. 2,3 Capozza found that physicians and nurses caring for oncology patients perceived their own professional group as possessing more uniquely human traits than the patient group. 2 A study of a variety of nursing showed that denial of uniquely human traits (reasoning, rationality, morality and intellectual ability) to patients was associated with lower levels of stress among nurses with high levels of organizational and affective commitment, suggesting that infrahumanization is a subconscious coping strategy to reduce the emotional burden of caring for patients. 3 Those suffering from critical illness are particularly vulnerable to this unintentional dehumanization. In an effort to refocus care of the critically ill to a more person-centered lens, several initiatives have been advocated (Figure 1 ), including diaries, liberal visitation policies, involvement of relatives in basic patient care and opportunities for relatives to be present during resuscitation. 4, 5, 6 There seems to be a conflict between what feels intuitively right (to humanize patients) and what health care professionals do to protect themselves against burnout and emotional burden (dehumanize patients). Equally important is what effect these interventions may have on family members. Objectives: To systematically review and evaluate the effects of humanized care of the critically ill, on empathy among health care professionals, anxiety among relatives and burnout and compassion fatigue in both groups. Methods: MEDLINE, PsycINFO, Embase, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), ProQuest Dissertations were searched from inception to 29th June 2017 for studies that investigated the effects of interventions with potential to humanize care of the critically ill, on the following outcomes: empathy among critical care professionals, anxiety among relatives and burnout and compassion fatigue in either group. We defined a humanizing intervention as: one with substantial potential to increase physical or emotional proximity to the patient. Two reviewers independently selected studies, extracted data, assessed risk of bias and data quality. Results: Twelve studies addressing four discrete interventions (liberal visitation, diaries, family participation in basic care and witnessed resuscitation) and one mixed intervention were included. Ten studies measured anxiety among 1055 relatives. Two studies measured burnout in 288 critical care professionals. None addressed empathy or compassion fatigue. Eleven of the included studies had an overall high risk of bias.

No pooled estimates of effect were calculated, as a priori criteria for data synthesis were not met.

We found insufficient evidence to make any quantitative assessment of the effect of humanizing interventions on any of these psychological outcomes. We observed a trend towards reduced anxiety among family members who participated in basic patient care, liberal visitation and diary keeping. We found conflicting effects of liberal visitation on burnout among health care professionals. There is no consensus on the optimal instrument(s) to assess physical function in ICU survivors. Simple one-item measures of physical tasks typically incorporated into therapy sessions may be the most attractive candidates given their ease of use and limited need for training of assessors. It is imperative that we ensure that potential measures are adequately tested to document reliability and responsiveness. Objectives: To train front-line clinicians to administer and to prospectively analyze the inter-rater reliability of 3 physical function measures in ICU survivors: Physical Function ICU Test-scored (PFIT-s), the 30 second sit-to-stand (30STS), and the two-minute walk test (2MWT).

We conducted a two-centre, prospective observational study with adult medical-surgical ICU patients in Hamilton, Ontario. Inclusion criteria: Patients with an ICU length of stay of 3 days or greater, who were mechanically ventilated for at least 24 hours, and who were able to ambulate independently with or without a gait aid prior to hospital admission. Outcome measures were the 4-item PFIT-s (10 points), the 30STS (# of stands), and the 2MWT (distance in m). For each patient, 2 blinded assessments were collected weekly within 24 hours of each other from ICU discharge to hospital discharge. We engaged multiple raters at each site; clinical schedules determined the rater for each assessment. We calculated inter-rater reliability using the intra-class correlation coefficient (ICC) for the total score for each measure using a 2way random effects model. We also calculated the standard error of the measurement (SEM), and the minimal detectable change at 90% confidence (MDC 90 understand the complex processes related to surrogate decision-making to improve both patient-centered and family-centered outcomes. Table 1   Table 2   Table 3 Introducing 3 Patients and families desire compassion, defined as an action-oriented expression of empathy. 4 The 3 Wishes Project is a compassioncentered EOL project that aims to perform at least three acts of compassion for dying patients and/or their families. 5 This project was shown to dignify the patient, create positive memories for families, and call forth compassion in clinicians. 5 Objectives: The objective of this study is to understand facilitators of and barriers to implementing the 3 Wishes Project in a single center community ICU.

We piloted a compassion centered EOL project from January 1st to June 30th, 2018, and assessed its implementation with mixed methods. At inception, an environmental scan was performed with key stakeholders. Based on the perceived gaps, two interventions were applied: engagement (small group sessions, quarterly reports, 1:1 mentoring) and empowerment (resources and financial support). The main quantitative measure was monthly enrolment rate. Secondary measures included the number of staff who enrolled patients for the first time, the number of compassionate acts per patient enrolled, and the financial cost of each act of compassion. To understand experience during implementation, seven semi-structured interviews with key stakeholders were conducted with six clinicians who implemented the 3 Wishes Project for their patient and one clinician who was involved in the initial environmental scan. Quantitative data were analyzed using appropriate statistical process control while qualitative data were analyzed in triplicate using a qualitative descriptive approach. Results: By the end of the pilot phase, 14 patients were enrolled and 61 wishes were implemented. 13.7% of dying patients were enrolled monthly. In addition, 9 clinicians enrolled a patient for the first time into the 3 Wishes Project. 1.5 clinicians per month enrolled a patient for the first time and 4.6 acts of compassion were performed per patient without additional financial cost. Interviews identified four facilitators: a shared vision for sparking change, research team integration with frontline staff, a collaborative learning environment, and available resources for staff to implement acts of compassion. Two barriers identified were: the differential manifestation of the project within different sub-cultures of the ICU, and the unclear process to fulfill an act of compassion. In addition, qualitative interviews suggested the possible benefits of two next steps: a point of care collaborator across nursing lines to spread awareness and expertise, and maintaining focus on the personalization of acts of compassion.

The pilot phase of a compassion-centered EOL project was successfully implemented for a small proportion of dying patients and their families in our community ICU. Key facilitators included a shared vision, research-clinical team partnership, a collaborative learning environment, and resources to empower staff. Key areas to be aware of during future implementation include differential uptake of interventions within sub-cultures, and maintaining a clear operational process. Based on staff feedback, we have developed the next steps to expand the 3 Wishes Project in our community ICU. (0.5%) had a tracheostomy and were ventilated and 15 (0.1%) were dialyzed. The prevalence of tracheostomy increased with time, and comprised 7408 (6.7%) patient days in the cohort. Inpatient mortality decreased over time. Inpatient mortality was 6.7% overall, 7% in patients with tracheostomy, 5.9% with non-invasive ventilation and 8.2% with a tracheostomy and ventilation. Conclusion: Device dependent patients comprised a small proportion of ICU admissions, that is increasing with time and is associated with a disproportionate number of ICU days. Inpatient mortality was similar to the entire cohort. A greater understanding of the prognosis of this population after critical illness is important for planning the future of Critical Care.

Critically ill patients experience poor quality of sleep and may develop abnormal sleep-related phenomena 1,2 . Timely management of sleep disturbances for critically ill patients is vital due to poor health outcomes such as the development of delirium, prolonged stays in the intensive care unit (ICU), and increased mortality 3-6 . Critically ill patients may exhibit disturbed diurnal rhythms with altered patterns of melatonin secretion. Melatonin is a molecule that exerts chronobiologic effects on sleep and biorhythms and administration of melatonin and melatonin receptor agonists (collectively referred to as MMA) have the potential to safely improve natural sleep, provide sedation, and may prevent or treat delirium 7, 8 . We conducted a systematic review to assess the efficacy of MMAs for the promotion of sleep and reduction in sedative use in the ICU.

We performed a systematic search of the following databases: MEDLINE, EMBASE, the Cochrane database, Web of Science, CINAHL, PsycINFO, Scopus, ClinicalTrials.gov and clinical practice guidelines. No language restrictions were applied and all study designs were eligible except for case studies. Studies could include critically ill adults and or children but not neonates. Two reviewers independently screened the retrieved articles for studies that evaluated the use of melatonin for sleep or reduction of sedatives in critically ill patients. Data from eligible studies is being extracted and after the quality assessment, data was pooled for statistical analysis if at least 2 trials reported the outcome of interest. Results: Our search strategy yielded 1431 citations, of which 1391 were excluded based on title and abstract. After full-text reviews of 40 citations, we identified 6 eligible RCTs with a total of 343 patients; 5 ongoing RCTs were identified. All included trials examined melatonin compared to either a placebo, a benzodiazepine, or non-drug sleep strategy. We found no difference in quantity of sleep between those who received melatonin and those who did not (mean difference -0.01, moderate quality evidence (n=3 studies, 119 subjects). We also found no difference in duration of mechanical ventilation or ICU length of stay. There was insufficient data to pool on sleep quality, agitation, or sedative drug consumption. Adverse events were rarely identified.

We found limited moderate-quality evidence that melatonin does not alter sleep quantity compared to non-melatonin strategies. Furthermore, we found the methods for assessing sleep and defining sedative consumption varied between trials limiting our ability to pool results.

Critically ill patients are at high risk of developing delirium with reported rates of up to 80%. [1] [2] [3] Some studies have shown abnormal melatonin concentrations to be associated with post-operative and intensive care unit (ICU) delirium. 4,5 Exogenous melatonin and melatonin agonists (MMA) have the potential to decrease the incidence and severity of delirium through their regulation of the circadian rhythm as well as hypnotic and sedative-sparing effects. [4] [5] [6] [7] [8] [9] We conducted a systematic review on the efficacy and safety of MMA for the prevention and treatment of ICU delirium. Objectives: To assess 1) the effectiveness of MMA compared to placebo or alternative therapy for preventing and treating delirium in critically ill patients and to examine the effect of MMA administration on: 2) duration of delirium; 3) delirium-free and coma-free days; 4) duration of mechanical ventilation; 5) ICU and hospital length of stay; 6) mortality; 7) discharge disposition; 8) long term cognitive outcomes; and 9) adverse events. Methods: We used methods established by Cochrane to conduct this review. We searched the following databases (inception-June 2018) without language restriction: MEDLINE, Embase, PsychINFO, Cochrane Library, CINAHL, Web of Science, Scopus, and grey literature. We included all randomized (RCT) and non-randomized studies of critically ill patients that assessed MMA for the prevention or treatment of ICU delirium. Two reviewers independently screened the retrieved articles. Data from eligible studies was extracted and pooled for statistical analysis if at least 2 trials reported the outcome of interest. Results: We screened 638 records and included 6 published studies (n=1152 subjects); we identified 5 conference abstracts and 13 ongoing studies for future use. Of the 6 included studies, 4 were RCTs, 1 was a prospective observation study, and 1 was a retrospective chart review. Three studies evaluated ramelteon, 2 melatonin, and 1 L-tryptophan. We found MMA reduced the incidence of delirium (RR 0.53, 95% CI 0.31, 0.90; 6 trials; moderate quality evidence). We found no difference in the duration of delirium (MD -0.91, 95% CI -2.58, 0.76; 3 trials; moderate quality evidence). We also found no difference in the duration of mechanical ventilation, lengths of stay, or mortality. No trial reported on delirium or coma-free days, discharge disposition or cognitive outcomes. Adverse events were rarely identified. Conclusion: We found moderate-quality evidence that MMAs prevent delirium in critically ill patients. We found moderate quality evidence that MMAs do not shorten the duration of delirium or alter duration of mechanical ventilation. Methods: Blood monocytes, isolated from healthy donors and septic patients (in first 48h of sepsis) were differentiated into Mɸ and exposed to human umbilical cord (hUC) MSCs (obtained from Tissue Regeneration Therapeutics®, Toronto) in transwell plates for 48h. Mɸ phagocytosis was assessed using serum opsonized zymozan (SOZ) while their killing capabilities were tested using live E. coli. Protein expression was analyzed by Western blot. Mɸ were also isolated from peritoneal fluid (PLF) of septic rats challenged with cecal slurry (1g/kg, i.p.) 48h earlier, that been treated with UC-MSCs (10 mill/kg, i.v.) or placebo 4h after sepsis induction. Inflammation and bacterial clearance were assessed in PLF, BAL, and organs of the septic animals. Results: Phagocytic efficacy and bacterial killing capacities were significantly increased in Mɸ from both healthy donors and septic patients co-cultured with UC-MSCs than in control Mɸ. Mɸ exposed to MSCs expressed more HO-1, an enzyme with anti-inflammatory and bactericidal properties. Peritoneal macrophages isolated from animals subjected to abdominal fecal demonstrated greater phagocytosis of SOZ when taken from UC-MSC treated vs. vehicle treated animals. Macrophages also expressed more HO-1. The direct HO-1 inducer Hemin increased macrophage phagocytosis from vehicle but not from UC-MSC treated animals. In contrast, the HO-1 antagonist ZnPP decreased phagocytosis in Mɸ from UC-MSC treated animals to the levels seen in macrophages from vehicle treated animals. The HO-1 increase in Mɸ was dependent on pro-resolvin mediators secreted by UC-MSCs, specifically PGE2 and Lipoxin A4. Septic animals cleared bacteria and recovered faster, if treated with UC-MSCs. Conclusions: UC-MSCs are promising tool for sepsis treatment. UC-MSCs enhance macrophage phagocytosis and increase bacterial clearance, in part, via a mechanism involving UC-MSC induced HO-1 expression in macrophages. Methods: In 2016 we employed a quantitative social network design and sent surveys to all five Regional Medical Leads (RMLs) and all 52 Hospital Donation Physicians (HDPs) in Ontario to better understand their roles, practice context, and to map their social networks. Social network analysis was performed with raw survey data with NVIVO software to produce a map of Ontario's physician leadership model as well as individual maps for each hospital-based physician. Results: The social network maps included a sociogram of the entire network as well as maps comparing the five RML peer learning networks (i.e., RML connectivity to HDPs at the hospital level). We were able to illustrate the key local opinion leaders / social influencers at each of the hospitals. Also, a central part of the survey was to ascertain the current state of the HDP social network in terms of knowledge sharing and support. Many respondents viewed the implementation physician leadership and engagement roles as central facilitators of TGLNs vision in Ontario. At the same time, respondents felt that the implementation of the roles was problematic in that these roles were not clearly defined nor locally communicated to hospitals at the outset. HDPs provided varied answers as to what they perceived their role to be, the most frequently described role was to monitor performance/quality improvement. Conclusion: Social network mapping of the physician leadership model provides a better understanding of the functioning, and ongoing peer learning that occurs within the network. This kind of social network mapping also permits an ongoing evaluation of the network over time by tracking central information brokers' network positions.

Conclusion: The outcomes of this study will unfold the current meaning of "success" for the scientific community in organ donation and transplantation programs worldwide and inform the development of quality initiatives in organ donation programs.

Expressions of sympathy from clinicians may be welcome for grieving family members of patients who die in the intensive care unit (ICU). However, a recent randomized controlled trial evaluating a semi-structured condolence letter in France suggested increased symptoms of depression and post-traumatic stress amongst recipients 1 . Methods: A core component of the 3 Wishes Project is an invitation for nurses, physicians, physiotherapists and respiratory therapists-both staff and trainees alike-to write a few words to bereaved family members in a sympathy card, mailed 1-2 weeks after each death. For this analysis, we searched a qualitative database of 200 clinician and family interview transcripts. Data related to sympathy cards were independently coded by 2 investigators using conventional content analysis and a list of codes was developed by consensus. Results: We identified 27 transcripts from individual interviews (n=14 family members, n=11 clinicians) and 2 focus groups (n=8 clinicians) in which sympathy cards sent by the 3 Wishes Program were discussed in 3 participating centers (SJH, VGH, UCLA). In 16 (59.3%) transcripts, participants spontaneously discussed sympathy cards. In 11 (40.7%) transcripts, participants were explicitly asked to reflect on their experiences sending or receiving sympathy cards. Family members felt deeply touched by personalized messages in the cards and saw them as a heartfelt act of compassion by the ICU team. The cards were a welcome surprise and offered an appreciated connection to clinicians with whom they had a relationship. Families reported feeling warmly remembered and they were eager to tell their relatives, friends and other hospital staff about receiving the card. Clinicians viewed the cards as an opportunity to offer expressions of their shared humanity with families, reminding them that they and their loved one were not forgotten. Most staff were keen to write a few words to families of patients they cared for who they knew well enough to authentically express their sorrow. While some staff preferred to pen a message only if they directly cared for the patient, others were motivated to offer sentiments of condolence if they had a brief interaction with the patient or knew them indirectly through seeing their family in the ICU. Taking the time to discuss memories of a deceased patient in the company of a colleague offered an opportunity for reminiscing and closure. A unifying concept was that both family members and clinicians experienced sympathy cards as an important continuation of care extended to family members of deceased ICU patients. Sympathy cards symbolized a special post-mortem connection for both parties. Conclusions: Family members found sympathy cards to be a meaningful, compassionate gesture by the ICU team. Inviting staff who cared for deceased patients to offer personalized condolences in a card mailed to bereaved family members may foster sincere, valued expressions of sympathy when individualized and unstructured, as contextualized in the 3 Wishes Program. Conclusions: Pre-arrest factors associated with reduced odds of survival to discharge include existing comorbidities (e.g. active malignancy, chronic kidney disease), and admission diagnosis of sepsis, while intra-arrest factors include unwitnessed arrest, unmonitored arrest, non-shockable rhythm, arrest outside of daytime hours, and intubation during arrest. Intubation during arrest was associated with reduced odds of survival. These results may inform discussions with patients when determining goalsof-care during admission, and consideration when determining cessation of IHCA management.

Background: Organ donation after circulatory determined death (DCD) accounts for 17% of all deceased organ donors in Canada, a fraction of its theoretical potential 1 . Up to half of all potential DCD patients are unable to donate because they do not die within currently required time limits to minimize organ ischemic damage 2 . The inability to predict time to death results in additional stress for families, a reduced number of successful donors, and increased costs for the health system. The DePPaRT (Death Physiology and Prediction After Removal of Therapy) study captured vital signs waveform data from 654 patients undergoing withdrawal of life sustaining therapy (WLST) in 22 centres in Canada, the Czech Republic, and the Netherlands. As reduced vital signs variability is associated with illness 4,6,7 , we hypothesized that the loss of heart rate and blood pressure variability in the hour prior to WLST might be useful in predicting time to death after WLST.

Objective: To develop a model based on vital signs waveform variability capable of predicting whether a patient will die within the timelines required for organ donation (0.5, 1, and 2 hours after WLST). Methods: Vital signs waveform data was available prior to WLST in 567 patients. This data was processed to obtain beat-to-beat event times series from the ECG and arterial blood pressure waveforms (R peak to R peak interval (RRI), systolic, diastolic, and pulse blood pressures), using CIMVA 3, 4 . Each series was filtered to remove arrhythmias prior to the calculation of up to 53 measures of variability, using windows of 750 beats. We excluded patients that had prolonged WLST, namely patients with additional life supporting therapies removed after 10 minutes after the first act of WLST. Patients enrolled prior to and after March 2017 were used in the derivation (210 patients) and validation (105 patients) cohorts, respectively ( Figure 1 ). All variability features were normalized to have a mean of 0 and a standard deviation of 1. We used random survival forests 9 in R to develop a predictive model. The model yielded a probability of dying within each 15-minute interval up until 24 hours after WLST for each patient (Figure 2a ). Probabilities at specific times on these curves (t = 0.5, 1, and 2 hours) were used as scores to predict if a given patient would die within these times. Features were ranked based on their importance over a 10-fold cross validation of the training set. The model was retrained using only the highest ranked variables, adding one variable at a time. We used all 210 patients from the training set and the 15 features required for the AUC to plateau (Figure 2b ) in a final model tested on the validation set.

Results: The derived model employing 15 variability features achieved a median AUC of 0.77, 0.8, and 0.77 for death within 0.5, 1, or 2 hours, respectively, on the validation set ( Figure 3a ). Nearly 91% of the patients with the highest scores died within 2 hours of WLST (Figure 3b ). On our dataset, our model outperformed one of the highest performing models in the literature 5, 8 (Figure 3c) . Conclusion: For the first time, a predictive model using only heart rate and blood pressure variability data to predict time to death after WLST has been shown to achieve superior performance to models derived using clinical data 5 . In the future, we will combine and evaluate models incorporating both variability and additional clinical variables. whereas in 2011 or later, a RC was the PI on 14 (82%) grants.

As key members of CCCTG, RCs have led and collaborated on numerous abstracts, manuscripts, and grants. Both the annual volume of activity and the level of "contributorship" has increased over time. Grants with RCs as PIs have increased substantially since the introduction of the RC Grant competition in 2011. The productivity of CCCRCG has been supported by nationally funded initiatives from the CCCTG and we anticipate that this academic growth will be sustained in years to come. Introduction: A presumed consent model of organ donation assumes all people of a defined geographic area consent for deceased organ donation unless they have expressed otherwise. Various forms of presumed consent exist 1 that are often implemented to increase donation rates, but have yielded mixed results [2] [3] [4] . Literature reviews on the topic suggest that a presumed consent model is unlikely to increase donation rates unless done in a transparent manner with broad support of the public and healthcare professionals 2, 5 Introduction: IMGs play an integral part in many health care systems worldwide. 1 When they pursue clinical training in a different country, IMGs face the need to adapt to an unfamiliar working environment. 2, 3 The practice of critical care is complex, time-sensitive and highly dependent on inter-disciplinary teamwork. In fact, effective team work has been tied to better ICU patient outcomes. 4 Understanding the "rules of the game" within an ICU team may represent a unique challenge for IMGs starting a critical care fellowship. The inability or delayed ability to adapt to their new training environment may be problematic for the trainees and for patient care. In addition, the unique role of a critical care fellow within an ICU team is foreign to many IMGs who trained in countries without fellowship programs. IMGs may initially not fully grasp the dual, sometimes conflictual nature (supervisor-supervisee; leader-follower) of their new professional role.

Objectives: This study aims to better understand how IMGs experience their transition within multidisciplinary ICU teams during their critical care fellowship. More specifically, this project explores: 1) IMG fellows' perceptions of their role within the multiprofessional ICU team; 2) challenges encountered by IMG fellows as they transition into their new professional role; 3) strategies used by IMG fellows to overcome these challenges. We explored how known theories on professional transition apply to the ICU environment with the ultimate goal of developing evidence-informed initiatives to support IMG fellows and ICU teams during the early transition period in the fellowship. Methods: In this qualitative single center study, we conducted 16 individual interviews with IMG fellows who were enrolled in the adult critical care fellowship program of the University of Toronto. Fellow's perceptions of their role and transition within the ICU team were explored and iteratively analyzed through a constructivist grounded theory approach, including purposive sampling, inductive coding, constant comparison and inter-disciplinary theoretical construction of a model. Results: Participants came from Europe, Central/South America, North America, Australia, Asia and the Middle East. Our analysis revealed that most of the participants had a limited understanding of the role of a fellow. For many fellows, this uncertainty translated into an initial lack of confidence in their ability to fulfill their role. The North American model of multidisciplinary ICU team (composition and roles) was perceived as a huge challenge. As they tried to work within the ICU team, participants reported experiencing many losses: autonomy, appreciation, efficiency, skills, and personal work standards. Fellows maneuvered this period of transition by relying on honed clinical skills, building trust with ICU team members, changing attitudes towards teamwork, or seeking social support. Others described a period of resistance where they actively challenged the system, the team or their colleagues. Conclusion: Our preliminary findings show that IMGs who have to transition into the role of a fellow within an inter-disciplinary ICU team encounter unique challenges. Uncertainties experienced at the beginning of the fellowship lead to a dynamic process of collapse and re-construction of their professional identity. Such findings will directly Background: Cirrhotic patients who receive mechanical ventilation are known to have exceptionally poor outcomes, with a reported mortality rate in excess of 35% 1,2 . In this study, we analyzed Healthcare Cost and Utilization Project (HCUP) National Inpatient Study (NIS) database to learn more about this high-risk population.

Objectives: The purpose of this study was to examine the impact of various comorbidities and/or interventions on mortality in this patient subpopulation. Further, we examined the impact of these factors on hospital length of stay (LOS) as well as the total financial cost per hospitalization. Methods: A retrospective analysis was performed on the HCUP NIS database from years 2005-2014. To select our subpopulation, the following inclusion criteria were applied: a) over the age of 18 years; b) assigned a diagnosis of cirrhosis (International Classification of Diseases 9th edition [ICD-9] code 571) and c) assigned an ICD-9 procedure code for mechanical ventilation (96.7). Multiple regression was used to assess the association between specific patient factors on in-hospital mortality, LOS and total hospital charges while adjusting for age, sex, race, Charlson comorbidity category, primary payer source, median income in the patient's residential area, elective versus emergency admission, location, size, and teaching status. Conclusions: There are several comorbidities associated with increased mortality amongst mechanically ventilated cirrhotic patients, including hepatorenal syndrome, sepsis, and renal failure. Procedures on this high-risk population were generally associated with improved mortality rates but significantly longer hospital stays and higher financial costs. Our results reinforce the notion that mechanically ventilated cirrhotics are a high-risk and expensive population with generally poor outcomes. Patients with impaired renal function and suspected sepsis should be treated carefully as they have an even greater risk of in-hospital mortality. Our work outlines a need for further investigation in order to better manage and treat this subpopulation of patients.

MAP recordings from the radial artery and non-invasive measurements of rSO2 by NIRS were obtained during the first 24-72 hours in the ICU. COx was iteratively calculated as the moving Spearman correlation coefficient (rho) between rSO2 and MAP with a given moving window length in one-minute steps. A 60 min moving window is shown here. Statistically significant COx values (p<0.01) are shown in red in the upper right panel. Introduction: Despite an increasing literature suggesting the poor performance of VAP as a quality measure of the care of mechanically-ventilated patients (), the only Accreditation Canada standard pertaining specifically to these patients relates to VAP prevention and treatment. The concept of Ventilator-Associated Event (VAE), introduced by the CDC/NHSN as a more suitable measurement in the evaluation of clinical care and outcome in these patients. Objective: We wished to 1) test the hypothesis that VAE identification adds value to current VAP surveillance data in a mixed med-surg ICU population, 2) to extrapolate from these data the number of potentially-missed VAEs during this time period. Methods: We retrospectively reviewed the charts of ICU patients previously identified with VAP between January 2009 and September 2016 and applied the CDC/NHSN criteria for VAE occurring 7 days before or after their designated VAP date. Data were merged into a preexisting ICU database. We first compared clinical/outcome data between patients intubated/ventilated (I/V) ≤ 2days (d) with those where and those I/V >2d (Table 1) . We then compared the same parameters for 1) VAP cases with those patients without VAP but similarly I/V >2d, as well as 2) VAP cases based on whether they also met VAE criteria (Table 2 ). Finally, we compared our data with those from a similar published Canadian ICU population in order to estimate the number of "missed" cases of VAE in our population. Results: Of 7919 ICU admissions, 1758 (22%) were I/V >2d, of which 143 cases (8%) of VAP were identified; 47/143 (33%) had coexisting VAE (VAC 36%, iVAC 30%, "VAE-VAP" 34%). Patients I/V >2d comprised a sicker, older population than those I/V ≤ 2d (Table 1) with differences in case mix and pre-ICU origin, increased LOS and mortality (icu & hosp), prop of ICU/hosp-days, ventilator utilization and ICU readmission. Patients with VAP showed differences in case mix and pre-ICU origin when compared those without VAP (Table 2) , as well as increased LOS (icu & hosp), % of ICU/hospital-days, % of admissions with LOSicu>7d and utilization of ventilator days. VAP patients with coexisting VAE were similar to those without VAE, except for a larger number of transfers to another ICU/institution. This may explain the higher % of ICU/hospital-days and the trend towards decreased ICU readmission rate and hospital LOS. NB only 1/3 of VAE patients had concurrent VAE-derived VAP Comparison with VAP and VAE data from a similar Canadian ICU population showed a similar distribution of ventilator-related parameters. We estimated from this comparison that at least 117 cases of VAE were missed by virtue of not having concurrent VAP identification. Conclusions: In our ICU patient population, the -Significant differences in resource utilization and clinical outcomes were observed when comparing patients ventilated >2 VS ≤2 days or whether VAP positive vs negative.

-However patients with VAP who had concurrent VAE were similar to those without VAE except for a greater proportion of patients transferred to another institution/ICU. -We estimate that 117 cases of VAE were potentially missed, which limits evaluative comparison between VAE and traditionally-identified VAP. It seems likely that these parameters reflect different patient mix, and that quality reviews should consider them as complementary information. Table 1   Table 2 

Refinement, scoring, and validation of the Family Satisfaction in the Intensive Care Unit (FS-ICU) survey

A Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Healthcare Professionals

Maslach burnout inventory

Relationship between ICU nurses' moral distress with burnout and anticipated turnover

Retention of critical care staff

Nurse burnout and quality of care: cross-national investigation in six countries

Burnout and medical errors among American surgeons

The shocking cost of turnover in health care

Prospective cohort study protocol to describe the transfer of patients from intensive care units to hospital wards

Struggle with a gap between intensive care units and general wards

Organizing Safe Transitions from Intensive Care. Nursing Research and Practice

A multi-center prospective cohort study of patient transfers from the intensive care unit to the hospital ward

Antimicrobial efficacy of a new chlorhexidine-based device against Staphylococcus aureus colonization of venous catheters

Attributable mortality of central line associated bloodstream infection: systematic review and meta-analysis

Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System

Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)

Pulseless electrical activity with witnessed arrest as a predic-tor of sudden death from massive pulmonary embolism in outpatients

Testing low-risk patients for suspected pulmonary embolism: a decision analysis

Incidence and predictors of repeated computed tomographic pulmonary angiography in emergency department patients

Computed tomography-an increasing source of radiation exposure

Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography

Incidence and predictors of contrast-induced nephropathy follow-ing CT-angiography for clinically suspected acute pulmonary embolism

Contrast nephropathy following computed tomography angiography of the chest for pulmonary embolism in the emergency department

Prospective Study of the Incidence of Contrast-induced Nephropathy Among Patients Evaluated for Pulmonary Embolism by Contrast enhanced Computed Tomography

Contrast-induced nephropathy in patients with chronic kidney disease undergoing computed tomography: a doubleblind comparison of iodixanol and iopamidol

A comparison of contemporary definitions of contrast nephropathy in patients undergoing percutaneous coronary intervention and a proposal for a novel nephrop-athy grading system

Contrast-induced nephropathy and long-term adverse events: cause and effect?

Contrast nephropathy after coronary angiography

Electronic medical record review as a surrogate to telephone follow-up to establish outcome for diagnostic research studies in the emergency department

Hospital-acquired renal insufficiency: a prospective study

Derivation of a simple clinical model to categorize patients' probability of pulmonary embolism: increasing the model's utility with the SimpliRED D-dimer

et al for the Christopher Study Investigators. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography

Effect of Early vs. Delayed Initiation of Renal Replacement Therapy on Martality in Critically Ill Patients with Acute Kidney Injury: The ELAIN Randomized Clinical Trial

Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit

Comparison of standard and accelerated initiation of renal replacement therapy in acute kidney injury

One-year outcomes in survivors of the acute respiratory distress syndrome

Quality of life in adult survivors of critical illness: a systematic review of the literature. Intensive care medicine

Severe and early quadriceps weakness in mechanically ventilated patients

Feasibility and safety of in-bed cycling for physical rehabilitation in the intensive care unit

The Admission Hamilton Early Warning Score (HEWS) Predicts the Risk of Critical Event during Hospitalization

Examining the utility of the Hamilton early warning scores (HEWS) at triage: Retrospective pilot study in a Canadian emergency department

Impact of socioeconomic status on mortality and unplanned readmission in septic intensive care unit patients

Engaging Communities in Health System Change -The Code Red Project in Hamilton

Physiological Responses to Passive Exercise in Adults Receiving Mechanical Ventilation

Impact of Very Early Physical Therapy During Septic Shock on Skeletal Muscle: A Randomized Controlled Trial

Very Early Passive Cycling Exercise in Mechanically Ventilated Critically Ill Patients: Physiological and Safety Aspects -A Case Series

Hemodynamic and metabolic effects of passive leg movement in mechanically ventilated patients

Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

Stem Cell-based Therapies for Sepsis

Alveolar-like Stem Cell-derived Myb(-) Macrophages Promote Recovery and Survival in Airway Disease

Neutrophil dysregulation during sepsis: An overview and update

The changing role of palliative care in the ICU

Comparison of Site of Death, Health Care Utilization, and Hospital Expenditures for Patients Dying With Cancer in 7 Developed Countries

Dying in Canada: is it an institutionalized, technologically supported experience?

The use of life-sustaining treatments in hospitalized persons aged 80 and older

What matters most in end-of-life care: perceptions of seriously ill patients and their family members

Reasons for dissatisfaction: a survey of relatives of intensive care patients who died

Half the families of intensive care unit patients experience inadequate communication with physicians

Impact of critical care medicine training programs' palliative care education and bedside tools on ICU use at the end of life

Critical care services in Ontario: a survey-based assessment of current and future resource needs

Factors associated with family satisfaction with end-of-life care in the ICU: a systematic review

Using standardized family members to teach communication skills and ethical principles to critical care trainees

The Critical Care Communication project: improving fellows' communication skills

Let's Talk Critical. Development and Evaluation of a Communication Skills Training Program for Critical Care Fellows

Communication skills training curriculum for pulmonary and critical care fellows

The top attributes of excellence of intensive care physicians

A guide for the design and conduct of self-administered surveys of clinicians

Increasing prevalence of medically complex children in US hospitals

Talking with parents about end-of-life decisions for their children

Circumstances surrounding end of life in a pediatric intensive care unit

Characteristics of deaths in paediatric intensive care: a 10 year study

When children die: Improving palliative and end-of-life care for children and their families

Pediatric palliative care in Canada in 2012: a cross-sectional descriptive study

Evidence-based guidelines for supportive care of patients with Ebola virus disease

Ottawa: CBS; c2016

Toronto: TGLN; c2018

Organ Donation and Transplantation in Canada. Ottawa: Parliamentary Information and Research Service

World Health Organization. International Guidelines for the Determination of Death-Phase 1

Achieving donor management goals before deceased donor procurement is associated with more organs transplanted per donor

Pediatric Prolonged Mechanical Ventilation: Considerations for Definitional Criteria

Association of Timing of Tracheostomy on Clinical Outcomes in PICU Patients

Determinants of Antibiotic Tailoring in Pediatric Intensive Care: A National Survey

Mechanical Ventilation Strategies in Children With Acute Lung Injury

Dehumanization and infrahumanization

Deumanizzazione del paziente oncologico nei contesti medici

Patients are not fully human: a nurse's coping response to stress

A plan for improving the humanisation of intensive care units

Use of a personal diary written on the ICU during critical illness

Family presence during resuscitation: A Canadian Critical Care Society position paper

Physicians' perceptions and attitudes regarding inappropriate admissions and resource allocation in the intensive care setting

The Development of a Machine Learning Inpatient Acute Kidney Injury Prediction Model

An Interpretable Machine Learning Model for Accurate Prediction of Sepsis in the ICU

Predictors of In-Hospital Mortality After Rapid Response Team Calls in a 274 Hospital Nationwide Sample

The acute hospital setting as a place of death and final care. A qualitative study on perspectives of family physicians, nurses and family carers

Dying in Canada: is it an institutionalized, technologically supported experience?

An Interhospital, Interdisciplinary Needs Assessment of Palliative Care in a Community Critical Care Context

Sympathy, empathy, and compassion: A grounded theory study of palliative care patients' understandings, experiences, and preferences

Personalizing Death in the Intensive Care Unit: The 3 Wishes Project

Three decades of pediatric intensive care: Who was admitted, what happened in intensive care, and what happened afterward

Functional recovery following critical illness in children: the "wee-cover" pilot study

Pediatric intensive care outcomes: development of new morbidities during pediatric critical care

Day 1 multiple organ dysfunction syndrome is associated with poor functional outcome and mortality in the pediatric intensive care unit

Chronic conditions among children admitted to U.S. pediatric intensive care units: their prevalence and impact on risk for mortality and prolonged length of stay*

Children with chronic conditions in pediatric intensive care units located in predominantly French-speaking regions: Prevalence and implications on rehabilitation care need and utilization

The chronically critically ill patient: pediatric considerations

Children with medical complexity: an emerging population for clinical and research initiatives

Melatonin therapy to improve nocturnal sleep in critically ill patients: encouraging results from a small randomised controlled trial

Meta-analysis: melatonin for the treatment of primary sleep disorders

Sleep disturbances in critically ill patients in ICU: how much do we know?

Sleeping on a problem: the impact of sleep disturbance on intensive care patients-a clinical review

Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit

Prevalence of sleep disturbances and long-term reduced health-related quality of life after critical care: a prospective multicenter cohort study

Effect of melatonin on sleep quality of COPD intensive care patients: a pilot study

Paediatric use of melatonin (Author reply to DJ Kennaway)

Potential use of melatonin in sleep and delirium in the critically ill

Diagnostic accuracy of delirium diagnosis in pediatric intensive care: a systematic review

Sleep and delirium in the intensive care unit

Correlation between serum melatonin circadian rhythm and intensive care unit psychosis after thoracic esophagectomy

Perioperative plasma melatonin concentration in postoperative critically ill patients: its association with delirium

Melatonin decreases delirium in elderly patients: a randomized, placebocontrolled trial

Paediatric use of melatonin (author reply to D. J. Kennaway)

Sleep-facilitating effect of exogenous melatonin in healthy young men and women is circadian-phase dependent

Postoperative delirium and plasma melatonin

Guidelines for intensive care unit design

Exploring performance obstacles of intensive care nurses

Psychometrics of the "Family-Centred Care Survey -Adult Scale

Stress among hospital nursing staff: Its causes and effects

The effects of collaboration on performance: A multilevel validation in project teams

Le fonctionnement interne des équipes de travail : conception et mesure. Revue canadienne des sciences du comportement

Anticipated turnover among nursing staff. Final Report. The University of Arizona

Further validation of a psychiatric symptom index in a normal population

References 1. Feasibility and Safety of Physical Therapy during Continuous Renal Replacement Therapy in the Intensive Care Unit

Effect of a condolence letter on grief symptoms among relatives of patients who died in the ICU: a randomized clinical trial

Alcohol withdrawal: a nationwide survey of inpatient treatment practices

A multi-centre survey of inpatient pharmacological management strategies for alcohol withdrawal

Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study

A prospective, randomized, trial of phenobarbital versus benzodiazepines for acute alcohol withdrawal

Delirium tremens: a double-blind comparison of diazepam and barbital treatment

A guide for the design and conduct of self-administered surveys of clinicians

Deceased Organ Donor Potential in Canada", report for the Canadian Institute for Health Information

Impact of a National Controlled Donation After Circulatory Death (DCD) Programme on Organ Donation in the UK: A 10 Year Study

CIMVA Exectuable Version 4.3 User Guide

Review and classification of variability analysis techniques with clinical applications

Predicting time to death after withdrawal of lifesustaining therapy

Non-linear dynamics for clinicians: chaos theory, fractals, and complexity at the bedside

Complex systems and the technology of variability analysis

Prediction of death in less than 60 minutes following withdrawal of cardiorespiratory support in ICUs. Critical care medicine

Random survival forests. The annals of applied statistics

The cuff leak test prior to extubation: A practice based on limited evidence

Promoting Professional Development of Critical Care Research Coordinators through Annual Workshops

Children's Hospital of Eastern Ontario

Vancouver General Hospital

10 Toronto Sick Children's Hospital

Children's Hospital of Eastern Ontario

Vancouver General Hospital

Canada 10 Toronto Sick Children's Hospital

Canada Survey of Canadian Intensive Care Physicians' Attitudes Towards a Presumed Consent Model for Deceased Organ Donation

Alexis 2,6 ; Dhanani

Lauralyn 4,5 ; Haj-Moustafa

6 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine

Increasing organ donation by presumed consent and allocation priority: Chile. Bull World Health Organ

A systematic review of presumed consent systems for deceased organ donation

Presumed Consent Legislation Failed to Improve Organ Donation in Chile

Evaluation of the Human Transplantation (Wales) Act: Impact Evaluation Report

An international comparison of deceased and living organ donation/transplant rates in opt-in and opt-out systems: a panel study

Health Professional Awareness and Attitudes on Organ and Tissue Donation and Transplantation, a Report from the Canadian Council for Donation and Transplantation

A guide for the design and conduct of self-administered surveys of clinicians

Proportional assist ventilation versus pressure support ventilation in weaning ventilation: a pilot randomised controlled trial

Evidence Supporting Clinical Use of Proportional Assist Ventilation: A Systematic Review and Meta-Analysis of

The impact of reducing intensive care unit length of stay on hospital costs: evidence from a tertiary care hospital in Canada

A pilot randomized trial comparing weaning from mechanical ventilation on pressure support versus proportional assist ventilation

Proportional assist ventilation versus pressure support ventilation in weaning ventilation: a pilot randomised controlled trial

Comparison of pressure support and proportional assist ventilation plus for weaning from mechanical ventilation in critically ill patients

Proportional assist ventilation versus pressure support ventilation in the weaning of patients with acute exacerbation of chronic obstructive pulmonary disease

Proportional assist ventilation with loadadjustable gain factors in critically ill patients: Comparison with pressure support

Ventilación con presión de soporte y ventilación proporcional asistida durante la retirada de la ventilación mecánica

International medical graduates (IMGs) needs assessment study: comparison between current IMG trainees and program directors

Recertifying as a doctor in Canada: international medical graduates and the journey from entry to adaptation

The link between teamwork and patients' outcome in Intensive Care Units

Can we make postoperative patient handovers safer? A systematic review of the literature

Standardized postoperative handover process improves outcomes in the intensive care unit: a model for operational sustainability and improved team performance

Trends and Outcomes in Mechanically Ventilated Cirrhotic Patients Cheung

Appelle Health Region

Appelle Health Region

Prognosis of patients with cirrhosis and chronic liver disease admitted to the medical intensive care unit

Outcome of patients with cirrhosis requiring intensive care unit support: prospective assessment of predictors of mortality

Understanding the Influence of Inter-Professional Relational Networks within Organ Donation Programs in Ontario: A Research Protocol and Preliminary Results Silva e Silva, Vanessa 1,2 ; Tranmer

Aguiar 2 ; Almost

Canada Using Non-Invasive Techniques to Explore Personalized Cerebral Perfusion Targets in Critically Ill Patients

Long-term cognitive impairment after critical illness. The New England journal of medicine

Predictors of Outcome With Cerebral Autoregulation Monitoring: A Systematic Review and Meta-Analysis. Critical care medicine

Cerebral autoregulation in cardiopulmonary bypass surgery: a systematic review. Interactive cardiovascular and thoracic surgery

Low brain tissue oxygenation contributes to the development of delirium in critically ill patients: A prospective observational study

Continuous time-domain analysis of cerebrovascular autoregulation using nearinfrared spectroscopy

Cerebral autoregulation after subarachnoid hemorrhage: comparison of three methods

Using the relationship between brain tissue regional saturation of oxygen and mean arterial pressure to determine the optimal mean arterial pressure in patients following cardiac arrest: A pilot proof-of-concept study

Determining the Upper and Lower Limits of Cerebral Autoregulation With Cerebral Oximetry Autoregulation Curves: A Case Series

Real-time continuous monitoring of cerebral blood flow autoregulation using near-infrared spectroscopy in patients undergoing cardiopulmonary bypass

Impaired cerebrovascular autoregulation in patients with severe sepsis and sepsisassociated delirium. Critical care

Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury. Critical care medicine

Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017 : Expert opinion of the Working Group on Prevention, AKI section, European Society of Intensive Care Medicine. Intensive care medicine

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive care medicine

Of the 96 sessions presented, 37 (39%) were related to PG&D, 35 (36%) ED, and 24 (25%) RR. Amongst the 122 speakers, the majority were RCs 81 (66%), with CI and IE representing 21 (17%) and 14 (11%) of speakers respectively. Speakers were rated 2008 times. The average rating was 4.4 (SD 0.74) (very good) on a 1-5 scale; 52% of ratings were 5 (excellent). Using a Jonckheere-Terpstra test, it was determined that evaluation ratings are improving over time (p = 0.01). Workshop attendee comments provided positive feedback on the diversity of topics and speakers. RCs reported networking opportunities, interactive discussions and learning from more experienced RCs as the most valued aspects of the workshops. Areas for improvement included more time for group discussion and interactive sessions. Suggestions for future workshop content focused on practical day-to-day activities such as grant writing, budget preparation, consent and co-enrolment, regulatory requirements, time management, research methodology and increasing productivity. Conclusions: The Canadian Critical Care Research Coordinators have broad learning needs. Professional growth and development is highly valued. Attendees at national Workshops appreciate increasing their knowledge base, networking with colleagues, and interactive discussions. RCs desire education related to practical aspects of their

inform the design of new strategies to facilitate IMGs' transition into North American ICU fellowships.

Denomme, Justine 1 ; Isac, Michelle 1 ; Syed, Summer 1 ; Yu, Janice 2 ; Centofanti, John 3 Introduction: Accurate and efficient handover is critical in the transfer of postoperative surgical patients by anesthesiology to the cardiac intensive care unit (CVICU). A systematic review of postoperative handover identified an association between the quality of patient handover and patient harm 1 . One strategy to improve handover and prevent adverse events is the application of checklists to standardize communication and minimize omissions 2 . Our academic centre recently implemented a standardized handover tool for the transfer of postoperative cardiac surgery patients to the CVICU. Objectives: To assess completion of a novel handover tool 6-months postimplementation, and elicit attitudes and perceptions of anesthesiologists and members of the CVICU team about perioperative patient handover. Methods: Ethics review was completed via the local REB. Chart review began 6months post-implementation of the handover tool and included 373 consecutive patients who underwent cardiac surgery over a 3-month period. Completion of the 59 parameters on the handover tool was assessed for adherence, and compared to the anesthetic record and preoperative investigations to assess for quality and accuracy of information. Using an online database, a self-administered survey was created regarding perioperative handover of CVICU patients. The survey was pilot tested and broadly disseminated to all cardiac anesthesiologists as well as healthcare professionals working in the CVICU. Questions were designed using a 5-point Likert scale with opportunity for free text commentary. Results: 357 (96%) of the charts reviewed included a copy of the handover tool. The parameters most frequently completed (>80% of charts) included medical history, airway management, arterial lines, cardiac bypass duration, drug dosing, and the transferring anesthesiologist's name. Documentation regarding pacing, recent bloodwork, central lines, peripheral IVs, and time of transfer were completed in less than 80% of charts. The response rate to the survey was 111 of 154 stakeholders (72%). 72% of respondents felt the handover tool improved the handover process and 62% felt it improved handover efficiency. No respondents felt the tool worsened handover. The majority felt the tool improved the transfer of important details of intraoperative care. The tool also enhanced verbal communication by anesthesiology trainees, standardized handover among anesthesia providers, and allowed access to important perioperative details after handover was completed. Barriers to success of the handover tool included a lack of awareness of its existence and nominal completion. Barriers to the effectiveness of overall patient transition included: insufficient clearance of physical space during patient transfer, lack of attendance of the cardiac surgeon and ICU attending during handover, and difficulty hearing verbal handover at the bedside. Conclusions: The introduction of a handover tool for cardiac surgical patients has improved handover from the perspective of its users, and continues to be used with promising adherence 6-months post-implementation. It is a useful resource detailing important patient and surgical information, and continues to be used even after verbal handover was completed. Barriers to effective transition of patients into the ICU with high-quality handover were identified and can be targeted for continuous quality improvement interventions.

To optimize organ donation performance the nature and impact of complex factors need to be understood. Some factors are well known and might not be modifiable (contra-indications for transplant, age limit of organ donor, etc), but others (collaboration and relationships) that contribute to variations among similar hospitals in the same province, are poorly understood. Objectives: The overall aim of this research is to understand the nature and impact of relationships within the organizational context of organ donation programs in Ontario. Methods: We will employ an exploratory, prospective, diagnostic study consisting of three approaches: (1) to describe the characteristics of social networks of health care professionals of the organ donation programs (Social Network Analysis) and (2) to describe the organizational attributes and processes of on organ donation programs (Multiple Case-Study), and (3) to compare the influence of social networks and organizational attributes on the performance of organ donation programs (Network Comparison). The study sites will include Ontario hospitals designated as type A based on trauma centre level (Public Hospitals Act classification); and hospitals partners of the Ontario's Organ Donation Organization. At least five sites will be purposely selected to capture the greatest variability of settings possible. Results: We have initiated the study, signed a data protection agreement with Ontario's Organ Donation Organization, and we are now on the first site collecting data. Conclusion: Understanding the influences of informal networks on organ donation outcomes is essential to the development and informing of interventions to optimize performance. This research will increase organ donation rates in Ontario by providing to the scientific community a novel measure of organ donation programs' performance and by identifying successful collaboration paths during organ donation processes. We will present the development process of the research as well as preliminary findings.Introduction/Background: Cerebral autoregulation (CA) is a vascular reflex mechanism that responds to changes in systemic blood pressure in order to maintain constant cerebral blood flow. CA dysfunction during cardiac surgery, intracerebral hemorrhage and traumatic brain injury is associated with negative outcomes [1] [2] [3] . Less is understood about CA function in the setting of critical illness. We recently showed that cerebral oxygenation during critical illness was associated with delirium, which may be related to CA dysfunction 4 . We analyzed CA function in critically ill patients during the first 24-72 hrs in the ICU using near-infrared spectroscopy (NIRS)-based cerebral oximetry [5] [6] [7] [8] [9] . We developed a novel approach to derive mean arterial pressure (MAP) targets that may help optimize cerebral perfusion in individual patients. Objective: To identify putative MAP targets in critically ill patients using NIRS-based cerebral oximetry. Methods: MAP and rSO2 were recorded simultaneously for up to the first 72 hours in ICU (n = 40 patients) by arterial catheter and NIRS, respectively. The cerebral oximetry index (COx) was computed as the moving Spearman correlation between MAP and rSO2 (Figure 1, 2) . Positive COx values were taken to reflect CA dysfunction while near-zero or negative COx values reflect intact CA [5] [6] [7] . We asked whether certain MAP values were associated with intact vs dysfunctional CA, and so binned the MAP values by COx (in bins of 0.05, from -1 to +1). This approach builds on previous research to identify optimal cerebral perfusion targets [5] [6] [7] [8] [9] [10] [11] . Results: COx signals were variable between patients, with some patients exhibiting greater periods of CA dysfunction than others. In a separate parallel analysis, we found that CA dysfunction was associated with the subsequent development of delirium (data not shown). After sorting MAP values into their associated COx bins, the resulting plots adopted four general patterns: negative slope (n = 18/40 patients, Figure 3A ), positive slope (2/40, Figure 3B ), flat (13/40, Figure 3C ) and complex (7/40, Figure 3D ). Plots with either positive or negative slopes clearly showed certain MAP 'danger' zones that were associated with CA dysfunction (high COx values), as well as relative 'safe' zones ( Figure 3A-B) . Danger zones and safe zones were separated by 8 ± 4 mmHg on average, with average MAPs of 76 ± 8 mmHg and 82 ± 10 mmHg, respectively. MAP targets were not readily discernable in plots with flat or complex morphologies from the other half of our study subjects ( Figure 3C-D) . The basis for the different plot morphologies is presently unclear, but may be related to the patients' position on the cerebral autoregulation curve. Conclusions: We outlined an approach for identifying patient-specific MAP targets using NIRS-based cerebral oximetry. This strategy may help preserve cerebral blood flow and reduce the risk of negative neurocognitive outcomes. Our data demonstrate how patient-specific parameters can inform the identification of MAP targets on a caseby-case basis, and suggest that the classic MAP target of 65 mmHg during critical illness may need revisiting [12] [13] . The ability to identify physiological targets in individual patients in real-time may allow precise personalized interventions that have the potential to improve outcomes for survivors of critical illness.