Perioperative Factors Associated With Postoperative Delirium in Patients Undergoing Noncardiac Surgery: An Individual Patient Data Meta-Analysis.

Importance: Postoperative delirium (POD) is a common and serious complication after surgery. Various predisposing factors are associated with POD, but their magnitude and importance using an individual patient data (IPD) meta-analysis have not been assessed. Objective: To identify perioperative factors associated with POD and assess their relative prognostic value among adults undergoing noncardiac surgery. Data Sources: MEDLINE, EMBASE, and CINAHL from inception to May 2020. Study Selection: Studies were included that (1) enrolled adult patients undergoing noncardiac surgery, (2) assessed perioperative risk factors for POD, and (3) measured the incidence of delirium (measured using a validated approach). Data were analyzed in 2020. Data Extraction and Synthesis: Individual patient data were pooled from 21 studies and 1-stage meta-analysis was performed using multilevel mixed-effects logistic regression after a multivariable imputation via chained equations model to impute missing data. Main Outcomes and Measures: The end point of interest was POD diagnosed up to 10 days after a procedure. A wide range of perioperative risk factors was considered as potentially associated with POD. Results: A total of 192 studies met the eligibility criteria, and IPD were acquired from 21 studies that enrolled 8382 patients. Almost 1 in 5 patients developed POD (18%), and an increased risk of POD was associated with American Society of Anesthesiologists (ASA) status 4 (odds ratio [OR], 2.43; 95% CI, 1.42-4.14), older age (OR for 65-85 years, 2.67; 95% CI, 2.16-3.29; OR for >85 years, 6.24; 95% CI, 4.65-8.37), low body mass index (OR for body mass index <18.5, 2.25; 95% CI, 1.64-3.09), history of delirium (OR, 3.9; 95% CI, 2.69-5.66), preoperative cognitive impairment (OR, 3.99; 95% CI, 2.94-5.43), and preoperative C-reactive protein levels (OR for 5-10 mg/dL, 2.35; 95% CI, 1.59-3.50; OR for >10 mg/dL, 3.56; 95% CI, 2.46-5.17). Completing a college degree or higher was associated with a decreased likelihood of developing POD (OR 0.45; 95% CI, 0.28-0.72). Conclusions and Relevance: In this systematic review and meta-analysis of individual patient data, several important factors associated with POD were found that may help identify patients at high risk and may have utility in clinical practice to inform patients and caregivers about the expected risk of developing delirium after surgery. Future studies should explore strategies to reduce delirium after surgery.

Study protocol: development and pilot testing of the Critical Care Pain Observation Tool for families (CPOT-Fam).

BACKGROUND: Patients in the intensive care unit (ICU) often have limited ability to communicate making it more difficult to identify and effectively treat their pain. Family caregivers or close friends of critically ill patients may be able to identify signs of pain before the clinical care team and could potentially assist in routine pain assessments. This study will adapt the Critical Care Pain Observation Tool (CPOT) for use by family members to create the CPOT-Fam and compare family CPOT-Fam assessments with nurse-provided CPOT assessments for a given patient. METHODS: This study will be executed in two phases: 1) Development of the CPOT-Fam - A working group of patient partners, ICU clinicians, and researchers will adapt the CPOT for use by family caregivers (creating the CPOT-Fam) and produce an accompanying educational module to deliver information on pain and how to use the tool. The CPOT-Fam will undergo preclinical testing with participants (i.e., members of the public and family caregivers of critically ill adults), who will complete the educational module and provide CPOT-Fam scores on sample cases. Feedback on the CPOT-Fam will be collected. 2) Pilot testing the CPOT - Fam family caregivers of critically ill adults will complete the educational module and provide information on the following: (1) demographics, (2) anxiety, (3) caregiving self-efficacy, and (4) satisfaction with care in the ICU. Family caregivers will then provide a proxy assessment of their critically ill loved one's pain through the CPOT-Fam and also provide a subjective (i.e., questionnaire-based including open-ended responses) account of their loved one's pain status. A comparison (i.e., agreement) will be made between family caregiver provided CPOT-Fam scores and ICU nurse-provided CPOT scores (collected from the provincial health information system), calculated independently and blinded to one another. Feasibility and acceptability of the CPOT-Fam will be determined. DISCUSSION: The results of this work will produce a family caregiver CPOT (i.e., CPOT-Fam), determine feasibility and acceptability of the CPOT-Fam, and compare pain assessments conducted by family caregivers and ICU nurses. The results will inform whether a larger study to determine a role for family caregivers in ICU pain assessment using the CPOT-Fam is warranted.

Factors associated with intention to receive vaccines for bacterial sexually transmitted infections among young HPV-vaccinated Canadian women.

OBJECTIVE: The aim of this study was to explore the acceptability of bacterial STI vaccines among young HPV-vaccinated Canadian women to inform future vaccine program implementation. METHODS: A 20-item cross-sectional questionnaire was administered from June 2019 to June 2020 to HPV-vaccinated participants of the pan-Canadian QUEST cohort. Multivariable logistic regression models assessed interest in chlamydia, syphilis, and gonorrhea vaccines using a priori variables and factors significant in bivariate analysis. RESULTS: Of the 1092 respondents analyzed, 82% indicated interest in receiving one or more future STI vaccines. Respondents had a median age of 19.6 years (range 16.9-23.4), and 75% of respondents identified as white/European descent. In adjusted analyses, intent to engage in positive health behaviours was associated with vaccine interest for syphilis (OR = 5.76, 95% CI 4.03-8.27), chlamydia (OR = 5.27, 95% CI 3.66-7.63), and gonorrhea (OR = 5.96, 95% CI 4.15-8.60). Willingness to pay for an STI vaccine was also associated with vaccine interest for syphilis (OR = 2.02, 95% CI 1.29-3.19), chlamydia (OR = 2.41, 95% CI 1.50-3.90), and gonorrhea (OR = 2.29, 95% CI 1.44-3.63). Ever having sexual intercourse and identifying as LGBTQ were significantly associated with vaccine interest for all infections, while age and ever being immunosuppressed were not significant in any adjusted models. CONCLUSION: Findings indicate over 80% of participants in a cohort of young HPV-vaccinated Canadian women are interested in receiving future bacterial STI vaccines. Further exploration of STI vaccine acceptability among diverse populations is required to inform future bacterial STI vaccine program implementation.

RéSUMé: OBJECTIF: Cette étude visait à explorer l'acceptabilité des vaccins contre les ITS bactériennes chez les jeunes Canadiennes vaccinées contre le VPH pour éclairer la mise en œuvre de futurs programmes de vaccination. MéTHODE: Un questionnaire transversal de 20 questions a été administré entre juin 2019 et juin 2020 aux participantes de la cohorte QUEST pancanadienne ayant été vaccinées contre le VPH. Des modèles de régression logistique multivariée ont permis d'analyser l'intérêt pour les vaccins contre la chlamydia, la syphilis et la gonorrhée à l'aide de variables a priori et des facteurs significatifs dans l'analyse bivariée. RéSULTATS: Sur les 1 092 répondantes analysées, 82 % ont manifesté l'intérêt de recevoir un ou plusieurs futurs vaccins contre les ITS. L'âge médian des répondantes était de 19,6 ans (intervalle 16,9­23,4), et 75 % s'identifiaient comme étant blanches/d'ascendance européenne. Dans les analyses ajustées, l'intention de s'adonner à des comportements de santé positifs était associée à l'intérêt pour les vaccins contre la syphilis (RC = 5,76, IC de 95 % 4,03­8,27), la chlamydia (RC = 5,27, IC de 95 % 3,66­7,63) et la gonorrhée (RC = 5,96, IC de 95 % 4,15­8,60). La volonté de payer pour un vaccin contre les ITS était aussi associée à l'intérêt pour les vaccins contre la syphilis (RC = 2,02, IC de 95 % 1,29­3,19), la chlamydia (RC = 2,41, IC de 95 % 1,50­3,90) et la gonorrhée (RC = 2,29, IC de 95 % 1,44­3,63). Le fait d'avoir déjà eu des rapports sexuels et le fait de s'identifier comme une personne LGBTQ présentaient une corrélation significative avec l'intérêt pour les vaccins contre toutes les infections, mais l'âge et le fait d'avoir déjà subi un traitement immunodépresseur n'étaient des facteurs significatifs dans aucun des modèles ajustés. CONCLUSION: Selon nos constatations, plus de 80 % des participantes d'une cohorte de jeunes Canadiennes vaccinées contre les VPH sont intéressées à recevoir de futurs vaccins contre les ITS bactériennes. Une exploration plus poussée de l'acceptabilité des vaccins contre les ITS dans des populations à forte mixité est nécessaire pour éclairer la mise en œuvre de futurs programmes de vaccination contre les ITS bactériennes.

Public perceptions during the first wave of the COVID-19 pandemic in Canada: a demographic analysis of self-reported beliefs, behaviors, and information acquisition.

INTRODUCTION: We explored associations between sociodemographic factors and public beliefs, behaviors, and information acquisition related to the coronavirus disease 2019 (COVID-19) to identify how the experiences of subpopulations in Canada may vary. METHODS: We administered a national online survey through Ipsos Incorporated to adults residing in Canada. Sampling was stratified by population age, sex, and regional distributions. We used descriptive statistics to summarize responses and test for differences based on gender, age, educational attainment, and household income using chi-squared tests, followed by weighted logistic regression. RESULTS: We collected 1996 eligible questionnaires between April 26th and May 1st, 2020. Respondents mean age was 50 years, 51% were women, 56% had a post-secondary degree, and 72% had a household income <$100,000. Our analysis found differences within the four demographic groups, with age effects most acutely evidenced. Respondents 65 years and older were more likely to perceive the pandemic as very serious, less likely to report declines in overall health, and more likely to intend to get vaccinated, compared to 18-29 year olds. Women overall were more likely to report negative outcomes than men, including stress due to the pandemic, and worsening social, mental/emotional, and spiritual health. Respondents 45 and older were more likely to seek and trust information from traditional Canadian news sources, while 18-29 year olds were more likely to seek and trust information on social media; overall, women and respondents with a post-secondary degree were more likely to access and trust online information from public health sites. CONCLUSION: This study found important demographic differences in how adults living in Canada perceived the COVID-19 pandemic, the impacts on their health, and their preferences for information acquisition. Our results highlight the need to consider demographic characteristics in tailoring the format and information medium to improve large scale acceptance and uptake of mitigation and containment measures.

Co-development of a transitions in care bundle for patient transitions from the intensive care unit: a mixed-methods analysis of a stakeholder consensus meeting.

BACKGROUND: Intensive care unit (ICU) patients undergoing transitions in care are at increased risk of adverse events and gaps in medical care. We evaluated existing patient- and family-centered transitions in care tools and identified facilitators, barriers, and implementation considerations for the application of a transitions in care bundle in critically ill adults (i.e., a collection of evidence-based patient- and family-centred tools to improve outcomes during and after transitions from the intensive care unit [ICU] to hospital ward or community). METHODS: We conducted a concurrent mixed methods (quan + QUAL) study, including stakeholders with experience in ICU transitions in care (i.e., patient/family partners, researchers, decision-makers, providers, and other knowledge-users). First, participants scored existing transitions in care tools using the modified Appraisal of Guidelines, Research and Evaluation (AGREE-II) framework. Transitions in care tools were discussed by stakeholders and either accepted, accepted with modifications, or rejected if consensus was achieved (≥70% agreement). We summarized quantitative results using frequencies and medians. Second, we conducted a qualitative analysis of participant discussions using grounded theory principles to elicit factors influencing AGREE-II scores, and to identify barriers, facilitators, and implementation considerations for the application of a transitions in care bundle. RESULTS: Twenty-nine stakeholders attended. Of 18 transitions in care tools evaluated, seven (39%) tools were accepted with modifications, one (6%) tool was rejected, and consensus was not reached for ten (55%) tools. Qualitative analysis found that participants' AGREE-II rankings were influenced by: 1) language (e.g., inclusive, balance of jargon and lay language); 2) if the tool was comprehensive (i.e., could stand alone); 3) if the tool could be individualized for each patient; 4) impact to clinical workflow; and 5) how the tool was presented (e.g., brochure, video). Participants discussed implementation considerations for a patient- and family-centered transitions in care bundle: 1) delivery (e.g., tool format and timing); 2) continuity (e.g., follow-up after ICU discharge); and 3) continuous evaluation and improvement (e.g., frequency of tool use). Participants discussed existing facilitators (e.g., collaboration and co-design) and barriers (e.g., health system capacity) that would impact application of a transitions in care bundle. CONCLUSIONS: Findings will inform future research to develop a transitions in care bundle for transitions from the ICU, co-designed with patients, families, providers, researchers, decision-makers, and knowledge-users.

Patient discharge from intensive care: an updated scoping review to identify tools and practices to inform high-quality care.

BACKGROUND: Critically ill patients require complex care and experience unique needs during and after their stay in the intensive care unit (ICU). Discharging or transferring a patient from the ICU to a hospital ward or back to community care (under the care of a general practitioner) includes several elements that may shape patient outcomes and overall experiences. The aim of this study was to answer the question: what elements facilitate a successful, high-quality discharge from the ICU? METHODS: This scoping review is an update to a review published in 2015. We searched MEDLINE, EMBASE, CINAHL, and Cochrane databases from 2013-December 3, 2020 including adult, pediatric, and neonatal populations without language restrictions. Data were abstracted using different phases of care framework models, themes, facilitators, and barriers to the ICU discharge process. RESULTS: We included 314 articles from 11,461 unique citations. Two-hundred and fifty-eight (82.2%) articles were primary research articles, mostly cohort (118/314, 37.6%) or qualitative (51/314, 16.2%) studies. Common discharge themes across all articles included adverse events, readmission, and mortality after discharge (116/314, 36.9%) and patient and family needs and experiences during discharge (112/314, 35.7%). Common discharge facilitators were discharge education for patients and families (82, 26.1%), successful provider-provider communication (77/314, 24.5%), and organizational tools to facilitate discharge (50/314, 15.9%). Barriers to a successful discharge included patient demographic and clinical characteristics (89/314, 22.3%), healthcare provider workload (21/314, 6.7%), and the impact of current discharge practices on flow and performance (49/314, 15.6%). We identified 47 discharge tools that could be used or adapted to facilitate an ICU discharge. CONCLUSIONS: Several factors contribute to a successful ICU discharge, with facilitators and barriers present at the patient and family, health care provider, and organizational level. Successful provider-patient and provider-provider communication, and educating and engaging patients and families about the discharge process were important factors in a successful ICU discharge.

Priorities for sexually transmitted infection vaccine research and development: Results from a survey of global leaders and representatives.

OBJECTIVE: To determine the sexually transmitted infection (STI) vaccine research priorities of global leaders in STI vaccine research, development, and service provision. METHODS: Global representatives attending the STI Vaccines: Opportunities for Research, Development, and Implementation symposium preceding the STI & HIV World Congress in 2019 were invited to complete an electronic survey. We asked participants to rank items by importance/priority for STI vaccine development for the following areas of focus: specific STIs (gonorrhea, chlamydia, syphilis, herpes, and trichomoniasis), broad research domains (basic science, funding, communication, program planning, and vaccine hesitancy), and specific research activities related to these domains. We calculated weighted value scores based on the ranking (e.g., first, second, third) and the total number of responses in order to produce a ranked list of the priorities. RESULTS: A total of 46 out of 97 (44%) symposium attendees responded to the survey. Gonorrhea was identified as the STI that should be prioritized for vaccine development, followed by syphilis with weighted value scores of 3.82 and 3.37, respectively, out of a maximum of five. Basic science (and vaccine development) was the domain ranked with the highest priority with a weighted value score of 4.78 out of six. Research activities related to basic science and vaccine development (including pre-clinical and clinical trials, and surveillance measures) and increased funding opportunities were the most highly ranked activities in the "STI vaccine development" and "research domains and activities" categories. CONCLUSION: Global leaders in attendance at the STI Vaccines symposium prioritized continued scientific work in vaccine development and program planning. Gonorrhea was identified as the highest priority infection, followed by syphilis.

Experiences and management of physician psychological symptoms during infectious disease outbreaks: a rapid review.

BACKGROUND: Prior to the COVID-19 pandemic, physicians experienced unprecedented levels of burnout. The uncertainty of the ongoing COVID-19 pandemic along with increased workload and difficult medical triage decisions may lead to a further decline in physician psychological health. METHODS: We searched Medline, EMBASE, and PsycINFO for primary research from database inception (Medline [1946], EMBASE [1974], PsycINFO [1806]) to November 17, 2020. Titles and abstracts were screened by one of three reviewers and full-text article screening and data abstraction were conducted independently, and in duplicate, by three reviewers. RESULTS: From 6223 unique citations, 480 articles were reviewed in full-text, with 193 studies (of 90,499 physicians) included in the final review. Studies reported on physician psychological symptoms and management during seven infectious disease outbreaks (severe acute respiratory syndrome [SARS], three strains of Influenza A virus [H1N1, H5N1, H7N9], Ebola, Middle East respiratory syndrome [MERS], and COVID-19) in 57 countries. Psychological symptoms of anxiety (14.3-92.3%), stress (11.9-93.7%), depression (17-80.5%), post-traumatic stress disorder (13.2-75.2%) and burnout (14.7-76%) were commonly reported among physicians, regardless of infectious disease outbreak or country. Younger, female (vs. male), single (vs. married), early career physicians, and those providing direct care to infected patients were associated with worse psychological symptoms. INTERPRETATION: Physicians should be aware that psychological symptoms of anxiety, depression, fear and distress are common, manifest differently and self-management strategies to improve psychological well-being exist. Health systems should implement short and long-term psychological supports for physicians caring for patients with COVID-19.

Allocation of intensive care resources during an infectious disease outbreak: a rapid review to inform practice.

BACKGROUND: The COVID-19 pandemic has placed sustained demand on health systems globally, and the capacity to provide critical care has been overwhelmed in some jurisdictions. It is unknown which triage criteria for allocation of resources perform best to inform health system decision-making. We sought to summarize and describe existing triage tools and ethical frameworks to aid healthcare decision-making during infectious disease outbreaks. METHODS: We conducted a rapid review of triage criteria and ethical frameworks for the allocation of critical care resources during epidemics and pandemics. We searched Medline, EMBASE, and SCOPUS from inception to November 3, 2020. Full-text screening and data abstraction were conducted independently and in duplicate by three reviewers. Articles were included if they were primary research, an adult critical care setting, and the framework described was related to an infectious disease outbreak. We summarized each triage tool and ethical guidelines or framework including their elements and operating characteristics using descriptive statistics. We assessed the quality of each article with applicable checklists tailored to each study design. RESULTS: From 11,539 unique citations, 697 full-text articles were reviewed and 83 articles were included. Fifty-nine described critical care triage protocols and 25 described ethical frameworks. Of these, four articles described both a protocol and ethical framework. Sixty articles described 52 unique triage criteria (29 algorithm-based, 23 point-based). Few algorithmic- or point-based triage protocols were good predictors of mortality with AUCs ranging from 0.51 (PMEWS) to 0.85 (admitting SOFA > 11). Most published triage protocols included the substantive values of duty to provide care, equity, stewardship and trust, and the procedural value of reason. CONCLUSIONS: This review summarizes available triage protocols and ethical guidelines to provide decision-makers with data to help select and tailor triage tools. Given the uncertainty about how the COVID-19 pandemic will progress and any future pandemics, jurisdictions should prepare by selecting and adapting a triage tool that works best for their circumstances.

A national cross-sectional survey of public perceptions of the COVID-19 pandemic: Self-reported beliefs, knowledge, and behaviors.

INTRODUCTION: Efforts to mitigate the global spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing Corona Virus Disease-19 (COVID-19) have largely relied on broad compliance with public health recommendations yet navigating the high volume of evolving information can be challenging. We assessed self-reported public perceptions related to COVID-19 including, beliefs (e.g., severity, concerns, health), knowledge (e.g., transmission, information sources), and behaviors (e.g., physical distancing) to understand perspectives in Canada and to inform future public health initiatives. METHODS: We administered a national online survey aiming to obtain responses from 2000 adults in Canada. Respondent sampling was stratified by age, sex, and region. We used descriptive statistics to summarize responses and tested for regional differences using chi-squared tests, followed by weighted logistic regression. RESULTS: We collected 1,996 eligible questionnaires between April 26th and May 1st, 2020. One-fifth (20%) of respondents knew someone diagnosed with COVID-19, but few had tested positive themselves (0.6%). Negative impacts of pandemic conditions were evidenced in several areas, including concerns about healthcare (e.g. sufficient equipment, 52%), pandemic stress (45%), and worsening social (49%) and mental/emotional (39%) health. Most respondents (88%) felt they had good to excellent knowledge of virus transmission, and predominantly accessed (74%) and trusted (60%) Canadian news television, newspapers/magazines, or non-government news websites for COVID-19 information. We found high compliance with distancing measures (80% reported self-isolating or always physical distancing). We identified associations between region and self-reported beliefs, knowledge, and behaviors related to COVID-19. DISCUSSION: We found that information about COVID-19 is largely acquired through domestic news sources, which may explain high self-reported compliance with prevention measures. The results highlight the broader impact of a pandemic on the general public's overall health and wellbeing, outside of personal infection. The study findings should be used to inform public health communications during COVID-19 and future pandemics.

Impact of social media interventions and tools among informal caregivers of critically ill patients after patient admission to the intensive care unit: A scoping review.

BACKGROUND: The use of social media in healthcare continues to evolve. The purpose of this scoping review was to summarize existing research on the impact of social media interventions and tools among informal caregivers of critically ill patients after patient admission to the intensive care unit (ICU). METHODS: This review followed established scoping review methods, including an extensive a priori-defined search strategy implemented in the MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane CENTRAL Register of Controlled Trials databases to July 10, 2020. Primary research studies reporting on the use of social media by informal caregivers for critically ill patients were included. RESULTS: We identified 400 unique citations and thirty-one studies met the inclusion criteria. Nine were interventional trials-four randomized controlled trials (RCTs)-and a majority (n = 14) were conducted (i.e., data collected) between 2013 to 2015. Communication platforms (e.g., Text Messaging, Web Camera) were the most commonly used social media tool (n = 17), followed by social networking sites (e.g., Facebook, Instagram) (n = 6), and content communities (e.g., YouTube, SlideShare) (n = 5). Nine studies' primary objective was caregiver satisfaction, followed by self-care (n = 6), and health literacy (n = 5). Nearly every study reported an outcome on usage feasibility (e.g., user attitudes, preferences, demographics) (n = 30), and twenty-three studies reported an outcome related to patient and caregiver satisfaction. Among the studies that assessed statistical significance (n = 18), 12 reported statistically significant positive effects of social media use. Overall, 16 of the 31 studies reported positive conclusions (e.g., increased knowledge, satisfaction, involvement) regarding the use of social media among informal caregivers for critically ill patients. CONCLUSIONS: Social media has potential benefits for caregivers of the critically ill. More robust and clinically relevant studies are required to identify effective social media strategies used among caregivers for the critically ill.

Factors associated with interest in bacterial sexually transmitted infection vaccines at two large sexually transmitted infection clinics in British Columbia, Canada.

OBJECTIVE: To explore sexually transmitted infection (STI) clinic client attitudes and preferences towards STI vaccines and STI vaccine programming in an urban clinic setting. METHODS: A 31-item questionnaire was administered during check-in by clinic clerical staff at two STI clinics in Vancouver, Canada. Demographic characteristics and preferences were summarised descriptively. Multivariable logistic regression models to assess factors associated with STI vaccine interest (reported as ORs) were constructed using a priori clinically relevant variables and factors significant at p≤0.05 in bivariate analysis. RESULTS: 293 surveys were included in analysis. 71.3% of respondents identified as male, 80.5% had college level education or higher and 52.9% identified as white/of European descent. The median age was 33. 86.5% of respondents reported they would be interested in receiving an STI vaccine, with a primary motivator to protect oneself. Bivariate analysis indicated several factors associated with vaccine interest, with differences for each infection. After adjusting for other variables, willingness to pay for an STI vaccine (OR=3.83, 95% CI 1.29 to 11.38, p=0.02) remained a significant factor for syphilis vaccine interest and intent to engage in future positive health behaviours remained a significant factor for chlamydia (OR=5.94, 95% CI 1.56 to 22.60, p=0.01) and gonorrhoea (OR=5.13, 95% CI 1.45 to 18.07, p=0.01) vaccine interest. CONCLUSION: Respondents expressed a strong willingness to receive STI vaccines. These valuable findings will inform for eventual STI vaccine programme planning and implementation.