Critical care ar2016

The Art and Science of Critical Care Medicine Annual Report of the Dalhousie University Department of Critical Care

2015-2016

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goals Compassion We aim to support patients and their families at all times, but especially during health crises that require intensive levels of medical care. We are always respectful of the sanctity of life and take care to provide comfort and dignity in death.

Accountability We strive to improve communication within the department, and raise the profile of the Department of Critical Care.

mission Accountability and excellence in medicine In the Department of Critical Care, we provide exemplary, compassionate and supportive care to critically ill patients, using a multidisciplinary approach that is based on evidence and updated regularly to reflect new research discoveries and improved best practices.

Respect & Trust We’re fostering an environment of open communication, respect and trust within the program.

Excellence We’re focused on providing exemplary care at all times.

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I M P R O V I N G P AT I E N T O U T C O M E S .

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The Department of Critical Care works to help strengthen critical care in Nova Scotia by: •

Advocating for the highest quality standardized critical care in the province

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Providing the leadership and expertise to develop an integrated program of critical care services within our province

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Facilitating recruitment of intensivists to hospitals and health centres around the province

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Recruiting, developing and retaining academic intensivists

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Supporting recruitment of a senior researcher whose focus is critical care medicine

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Leading the development and expansion of simulation education at Dalhousie University, the QEII Health Sciences Centre and across the province

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Delivering critical care continuing medical education to health care providers throughout the province

depth DEPTH OF EXPERTISE AND LEADERSHIP IN CRITICAL CARE

Message from Dr. Ward Patrick, Head/Chief, Department of Critical Care As the Department of Critical Care, we drive and support efforts to ensure the highest quality critical care is provided in Nova Scotia. Our members deliver critical care, advise hospital and government administrators on policy development, advocate for patients and their families, implement quality improvement initiatives, educate medical students, residents and our peers, and conduct research. As you will come to see in this report, we value our responsibility to ensure patients receive the best possible care, and families are supported, in what are most often the worst circumstances.

To that end, the Department of Critical Care includes a full roster of very talented and accomplished academic intensivists who are well positioned to continue to contribute extensively to the strengthening of critical care in hospitals and health centres in Nova Scotia and beyond. They are leading efforts locally and nationally to increase understanding and application of critical care medicine, and thus improve outcomes for critically ill patients.

In the next year, we will see the Pediatric ICU at the IWK become a division within the department and we will collaborate on academic and administrative initiatives that impact both groups. In addition to this, we continue to also have a professional and talented group at the Dartmouth General Hospital ICU, and they contribute greatly to our accomplishments as a whole department.

Notably, a number of Department of Critical Care members also serve provincial and national director and key advisory roles. As primary examples, Dr. Stephen Beed, intensivist and professor, is medical advisor of the Legacy of Life: Nova Scotia Organ and Tissue Donation Program; Dr. Rob Green, intensivist and professor, is medical director of Trauma Nova

Scotia; and Dr. Jennifer Hancock, intensivist and associate professor, is leading efforts to establish a national education program about organ and tissue donation for health care providers.

As department head, I have seen critical care develop as a discipline in Canada and here at Dalhousie as we have worked to establish a strong foundation of clinical, education and research expertise in critical care. Within the next year, we will enter into a new and more mature phase of critical care at Dalhousie. Our department will bid farewell to two senior members, Dr. Rick Hall, clinician researcher, and Dr. Bill Gallacher, clinician educator, whose experience and knowledge will be sorely missed. They are, however, actively mentoring newer members of our department who will help lead us into and shape the future of critical care. I will also be entering a new phase of my career, as I am stepping down as department head upon completion of my term.

I am confident the result of these changes and of our work to build a strong foundation of critical care expertise will be fresh perspectives and new directions to deliver the best possible care for patients and their families. I am grateful to have an incredibly skilled and dedicated team of academic intensivists and administrators in this department.

With this annual report, we aim to give you a better sense of critical care medicine, including who benefits, delivers, teaches, leads and investigates critical care. Should you have any questions, I would be more than happy to answer them.

Ward Patrick

Dr. Ward Patrick, MD, FRCPC, FACP Head & Chief, Department of Critical Care ward.patrick@nshealth.ca

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Exceptional care of 1,587 critically ill patients

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Support for thousands of family members in the worst of circumstances

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Consistently low readmission rates on all three intensive care units

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3 ICUs: QEII Health Sciences Centre (HI and VG sites) and Dartmouth General Hospital

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Best-practice projects underway to improve care of patients with delirium, prevent pressure ulcers and increase patient mobility

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A master’s prepared registered nurse in the role of quality leader dedicated to helping us ensure we continually deliver the best possible care

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All department members engaged in projects to continuously improve the care we deliver

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Department head co-leading efforts to create a provincial critical care system in Nova Scotia

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13 core department members providing care, education, advocacy and research

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2 faculty serving as directors of Legacy of Life: Nova Scotia Organ and Tissue Donation Program and Trauma Nova Scotia

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1 faculty leading efforts to establish a national education program about organ and tissue donation for health care providers

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1 faculty directing the national Perioperative Anesthesia Clinical Trials Network (PACT)

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114 residents from anesthesia, emergency medicine, internal medicine and the surgical specialties in the ICUs

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25 medical students in the ICUs

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6 of 13 critical care faculty members achieved the rank of professor

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8 studies and trials underway to improve care of critically ill patients

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$133,321 in research funding

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29 articles published in peer-reviewed journals to share what we have learned

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Department of Critical Care members provided care for 1,587 critically ill patients in 2015-2016 in three ICUs: the Halifax Infirmary (HI) and Victoria General (VG) sites of the QEII Health Sciences Centre, and the Dartmouth General Hospital.

care Critical compassion and communication

In June 2015, Kevin Crosby and his wife, Lorraine Rawlins, awoke in the night to a neighbour pounding on their door and yelling that their barn was on fire. Kevin, co-owner of Crosby Stables, ran out to save the eight horses that were stabled, but at the barn he was faced with a wall of smoke and flame and could only release one mare before he was forced to flee. He jumped on a tractor and drove it through the barn wall to free another mare and her foal.

The incident left Kevin with burns on his head, face, hands, arms and back, which were treated locally with topical antibiotics. He and Lorraine then turned their attention to dealing with the aftermath of the devastating fire.

Lisa Julien

A week later, Lorraine found Kevin unresponsive in their home.

After calling 911, paramedics rushed Kevin to the QEII Health Sciences Centre. Over the course of the week Kevin had developed sepsis—a serious, life-threatening infection.

At the QEII’s intensive care unit (ICU), Kevin was immediately intubated and put in a medically induced coma to aid his recovery. Lorraine was approached by Lisa Julien, research coordinator, who told the family they could enroll Kevin in a research study on a drug that reverses coagulopathy (irregular clotting due to infection). Dr. Rick Hall, professor of critical care and anesthesia, was leading the study.

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Kevin Crosby cont’d.

“It was very difficult because things were happening so fast,” says Lorraine. “Lisa explained what being in the study could mean for Kevin, and my daughter and I quickly decided it was the right thing to do. I soon found out that Lisa’s careful and compassionate approach would be carried through not only by her but by everyone on the critical care team.”

Kevin was enrolled in the study and underwent weeks of intensive care. His family gained a lasting appreciation of the critical care teams who had skillfully responded to their urgent needs.

“Kevin was in a coma for six days and in under two weeks he was strong enough to leave the ICU,” says Lorraine. “In that time, he had every type of expertise available to him. The first week was so hectic that I can’t remember some of the details, but I never once felt I didn’t know what was being done or what was needed. The team members were able to cut through the whirlwind of people, wires, tubes, screens and beeps so that I understood what was happening.”

Photo : Danique Rowsell

Now, more than a year after Kevin’s ordeal, Lorraine often reflects on the immediacy of the care he received. “The team is adamant about everything being done right and fast—the intensity really is amazing.”

And while Kevin is not able to remember being in the ICU, nor even the fire that landed him there, he knows that the exceptional care he received is what got him back in the saddle.

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Critical thinking, critical care

“Above all, I am a problem solver,” says Dr. Tobias Witter.

Dr. Witter and his colleagues in the Department of Critical Care treat patients whose bodies are failing them system by system and organ by organ. “Essentially, we see patients when something has gone very wrong,” he explains. “We need to stabilize the patient fast and at the same time figure out what’s going wrong so that we can then treat it just as quickly.”

Intensivists like Dr. Witter and Dr. Sarah McMullen thrive in this high-stakes, pressure-riddled work environment. “The patients we see are incredibly ill and need to be treated immediately,” says Dr. McMullen. “We meet these challenges with sound decision-making and a high level of specialized skills, but also with compassion.”

Dr. McMullen was the first resident to complete the then new Dalhousie Critical Care Residency Program. She joined the department upon graduation in 2010, marking the end to her more than 10 years of medical school and postgraduate training. Dr. McMullen is now part of the critical care team at both the QEII Health Sciences Centre and the Dartmouth General Hospital intensive care units. She also teaches residents, co-leads the critical care quality committee and champions the use of bedside echocardiography in critical care.

A New Brunswick native, Dr. McMullen knew as a third-year medical student she wanted to pursue critical care medicine.

“In the ICU, we can immediately see how the care we provide and the decisions we make in that care are affecting the patient—I like that there’s virtually no ‘wait and see.’ But the intensity surely isn’t for everyone.”

Intensivists in the Department of Critical Care are Dalhousie Medical School faculty who teach medical students and residents. They also have specialized training in medical disciplines outside of critical care such as in internal medicine, emergency medicine or anesthesia.

Dr. Witter, who was a senior intensivist in Germany before relocating to Halifax and becoming a member of the Department of Anesthesia, Pain Management & Perioperative Medicine and then the Department of Critical Care, provides both anesthesia and critical care at the QEII. He is emphatic about the need for a team-based approach: “Intensivists contribute specialized knowledge to the care of the patient, but so too do the many other professionals we work with every day in the ICU, including nurses, respiratory therapists, clergy, social workers, ward aids and more. It’s an all-handson-deck approach,” Dr. Witter adds. “We work together to do the best we can for the patient and their family, and on a 24/7 basis.”

It’s certainly intense work, but the Department of Critical Care has just the intensivists—and care team—to do it!

Bright lights, big decisions: The fast-paced life of an ICU Beeping monitors, drawn curtains, bustling staff, bright lights—intensive care units (ICUs) are hives of constant activity, where the most gravely ill patients receive the full and constant attention of the critical care team. ICUs get their name honestly: everything about these units is intense—from the treatments given, to the fierce concentration and focused care staff and families provide these vulnerable patients.

Patricia Daley and Cynthia Isenor manage the ICUs at the QEII Health Sciences Centre and Sharon Ingram manages the ICU at Dartmouth General Hospital. They have decades of experience as bedside nurses and, like all ICU nurses, have specialized training in critical care.

“The ICU isn’t for the faint of heart,” says Ms. Daley. “In addition to specific and specialized skills, our team has to be prepared for continuous intensity, which can and does wear on you.” When she and Ms. Isenor hire staff, critical thinking, eagerness to learn and communication are among the most valuable traits they seek in new team members.

“There isn’t time to mull over decisions and you never get to the point where you know everything,” adds Ms. Isenor.

In the ICU, families are forced to confront very difficult situations involving people they love in an environment that is designed for complicated medical interventions. “We provide family-centred care, recognizing that patients in the ICU are critically ill and require continuous monitoring, assessment, evaluation and treatment of life-threatening conditions,” says Ms. Isenor. “Involving family members— ensuring they understand what is happening and can make informed decisions—is integral to the care we provide every day.”

Appropriate care of patients in the ICU involves knowledge of some of medicine’s most complicated and delicate procedures and technologies: • • • •

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invasive or non-invasive ventilation continuous cardiac monitoring non-invasive hemodynamic monitoring (arterial lines, pulmonary artery catheters and PiCCO) critical care life support systems, including extra-corpeal membranous oxygenation (ECMO) and continuous renal replacement therapy (CRRT) administration of complex advanced practice medications, such as vasopressor and inotropic agents, anti-arrhythmics, paralytics, inhaled vasodilators, conscious and unconscious sedation fluid and volume resuscitation, including administration of blood products following massive transfusion protocols and rapid infusion protocols dialysis intracranial pressure monitoring

Complex acute care is led by the intensivist team, but bestpractice critical care involves consultation with professionals in pharmacy, nutrition, social work, spiritual care and more— a multidisciplinary approach that adds to the rush of activity in the ICU. But everyone has a crucial role to play to ensure these serious cases achieve the best possible outcomes. It is intense and exhausting work, but having the opportunity every day to tackle new challenges and help patients and families at their worst moments makes the ICU one of the most rewarding workplaces imaginable.

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Our mission is to provide exemplary, compassionate and supportive care to critically ill patients and to support families through a continuously evolving multidisciplinary and evidence-based approach. We strive to promote accountability and excellence in clinical care, research and education, and aim to foster a safe, transparent and collegial working environment.

To that end, the Department of Critical Care is leading projects to improve patient outcomes. A dedicated quality leader and quality team generates, coordinates and manages the department’s efforts to continually improve the care of critically ill patients.

improve Quality & patient safety

In October 2014, the Quality & Patient Safety Team established a three-year plan that includes the goals noted below, which will be re-assessed following the Accreditation Canada survey visit in 2017.

Critical Care Quality & Patient Safety Goals

CLINICAL BEST PRACTICE PROJECTS Delirium – awareness, assessment, prevention & management Pressure ulcer prevention Mobility project

TEAM PROCESSES / DECISION-MAKING Health care team function Family-centred care

Sustainability

INFECTION PREVENTION & CONTROL Ventilator-associated pneumonia Central line-associated blood stream infection Hand hygeine

MEDICATION SAFETY Medication event reporting & event prevention

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By broadening champions among all professions, the Team continues to build "quality strength." Front-line staff and physicians have taken the reins on several projects, and having a family/community voice at the table has introduced a new depth to discussions and decisions.

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The Quality Team continues to work to ensure consistent practice between sister units 3A and 5.2 ICU, minimizing risk introduced by unnecessary practice variations.

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The Team embraced provincial opportunities for improvement, becoming involved in the provincial Key Performance Indicators (KPI) development group, and contributing expertise to provincial discussions around the “Transport of Critically Ill Patients” and the “Identification of Inpatients Requiring Escalation of Care.”

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The Quality Team constantly seeks ways to identify risks and improve efficiency. Examples include identifying concerns regarding outdated infusion pump technology, and addressing cumbersome admission processes that sometimes register "known" patients as "unknown."

Quality Team successes in 2015-2016: •

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Under the stewardship of quality leader Karen WebbAnderson, the Quality Team provided indispensable leadership when the VG site flooded in the fall of 2015.

By supporting the health centre team and liaising between leadership and the front-line workers who bore the brunt of the impact, Ms. Webb-Anderson and ICU unit managers Patricia Daley and Cynthia Isenor helped ensure the well-being of the health care team and the ongoing provision of safe care during a very chaotic time. Following the flooding, the Quality Team went above and beyond to develop a robust Critical Care Surge Plan.

The Quality Team supported the integration of weekly “Medication Safety Huddles” into routine critical care practice, with a process for sharing between units and follow-up on identified gaps.

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Delirium was a central focus for our interdisciplinary team, leading to better understanding of the incidence of delirium in our units. Delirium is discussed several times per day during nursing reports and twice-daily rounds, and “Early Mobility” was implemented to prevent and limit the impact of delirium on our patients.

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The pressure injury prevention program has grown. This is fast becoming an area of focus for everyone involved in patient care, particularly bedside nurses. We now understand the incidence and prevalence of pressure injury in our units, and the use of evidence-based strategies to prevent pressure injuries and treat wounds is growing.

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Priorities for 2016-2017:

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Prepare for accreditation: The activities of hospitals and health centres in Canada are accredited by Accreditation Canada, which works through Canada's Qmentum Program to meet best practice standards and raise the quality of services. The ongoing accreditation process includes a number of milestones that allow health centres and their programs to assess whether they are meeting best practices in health care and, if not, to take action. Accreditation surveyors will be visiting our organization in the fall of 2017. Over the next year, the Critical Care Quality Committee will focus on further strengthening projects that improve patient safety and patient outcomes as part of the accreditation process.

Dr. Volker Eichhorn

Leadership and teamwork

The accomplishments of the Quality Team would not be possible without the dedication and contributions of team members and a vast network of health care professionals, administrators, patients and families. A few team members deserve special recognition and thanks:

Integrate the Daily Rounds Tool (DaRT) into more consistent practice: As consistency improves with data collection, the Team’s power for improvement will also grow.

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Dr. Volker Eichhorn and Dr. Janice Chisholm stepped up to support the Quality Team while Dr. Sarah McMullen, medical chair, was on maternity leave.

Continue to work as a united group: Reflecting membership from both 3A and 5.2, the Quality Team constantly seeks to make improvements in both units, capitalizing on strengths.

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The support of the interdisciplinary team, facilitated by quality leader Karen Webb-Anderson, is key to our success. Ms. Webb-Anderson brings boundless energy, a commitment to quality and attention to detail to her role.

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Improve completion rate of Family Surveys: The aim is to strengthen the voice of families in change.

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Improve and implement an updated approach to spontaneous daily awakening and spontaneous daily breathing trials in intubated and sedated patients: The Quality Team will work toward reducing the incidence of delirium in patients.

Family representative Jean Collier provides an invaluable voice to discussions, bringing to the table her experience both as a former nurse and as a relative of a family member cared for in one of our units.

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Seek opportunities to make process changes that support best practice: The Team strives to find “smart” improvements in a system with great front-line demands.

Unit managers Patricia Daley and Cynthia Isenor are amazing leaders who are fiercely committed to quality issues and care.

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Pharmacy clinical coordinator Dr. Meghan Mackenzie is responsive to the needs of patients and the Quality Team, and always available to lead with her expertise and grounded approach to change.

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I M P R O V I N G P AT I E N T O U T C O M E S T H R O U G H A N O V A S C O T I A N A P P R O A C H T O CRITICAL CARE

The Department of Critical Care, under the leadership of Dr. Ward Patrick, department head, is at the forefront of efforts to create a provincial critical care system in Nova Scotia. This work is an extension of the Department’s longstanding mandate to strengthen critical care in Nova Scotia by educating intensivists, conducting critical care research and supporting the leadership of its members on provincial and national initiatives related to critical care. Also, Dr. Jorin LindenSmith, site chief of the Dartmouth General Hospital ICU, and Dr. Gavin Morrison, site chief of the Pediatric ICU group, are both contributing members of the provincial critical care committee.

lead A critical care system in Nova Scotia The amalgamation of health districts across the province to form the Nova Scotia Health Authority (NSHA) has prioritized work to develop and implement a provincial strategy for critical care. The intent of this work is to ensure citizens can receive appropriate critical care close to their home, regardless of where they call home in Nova Scotia.

Part of the Department of Critical Care’s mandate is to increase critical care capacity in Nova Scotia and the Maritimes by educating intensivists, conducting critical care research and supporting the leadership of its members in provincial and national initiatives related to critical care. Fittingly, the Department, under the leadership of Dr. Ward Patrick, department head, is at the forefront of the most recent efforts to review critical care across Nova Scotia and submit recommendations for a provincial critical care system.

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lead There is also:

Critical care system cont’d.

Dr. Patrick co-chairs the Critical Care Provincial Work Stream Committee with Dr. Howard Wightman, ICU medical director, Valley Regional Hospital, and Sharon Stevens, senior director, Critical Care, NSHA. Dr. Jorin LindenSmith, site chief, DGH ICU, and Dr. Gavin Morrison, site chief, IWK ICU, are members of the Committee. The Committee was formed in December 2015 to assess and make recommendations about critical care services in the province. Its work has so far included gathering and reviewing data and information from all intensive care units (ICU) across the province, talking to many unit leaders to better understand the work of each unit, and meeting regularly for review and discussion.

The Committee found that there are 118 adult critical care beds (including ICUs, critical care units and cardiovascular intensive care units) in the province, and 86 adult intermediate medical care unit beds. Among the ICUs there are engaged and talented health care professionals providing the best care they can for critically ill patients.

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significant variability in patient volumes and patient acuity

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significant variability in physician specialist, nursing and clinical support resources

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different practices when caring for the same types of patients

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sporadic professional networking with no formalized system structure or oversight

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little outcomes data, utilization data that is not standardized and data reports lagging by several quarters or more

The Critical Care Provincial Work Stream Committee will ultimately make recommendations that will see the formal designation of ICUs across Nova Scotia by levels, as per the Canadian Critical Care Society guidelines. There will be clear role definitions for each unit, recommended care provider staffing and a robust communication network to facilitate prompt information flow.

“We intend for the critical care system to support the delivery of evidence-informed care appropriate to each patient’s condition. This follows the philosophy that patients should receive the right care at the right time in the right place,” says Dr. Patrick. “The envisioned system will also encourage outcomes measurement and continuous improvement, training and education of health care providers, and an enhanced structure for the critical care academic and research mandate.”

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U N D E R S TA N D I N G A N D I M P R O V E M E N T O F C R I T I C A L C A R E T H R O U G H E D U C AT I O N Department of Critical Care members, both at the QEII and DGH, spent hundreds of hours teaching and leading simulation sessions for medical students and residents in 2015-2016. Excellence in education is a department priority: we review and revise the education curriculum annually to ensure we graduate highly skilled, competent and compassionate leaders in critical care.

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One of kind: Critical care fellow to bring expertise in neurocritical care to Halifax

When Dr. Laurel Murphy finishes a neurocritical care fellowship in the United Kingdom, she will graduate as one of very few neurointensivists in Canada. Her hope is to be one of a kind in Halifax.

The Charlottetown native has plans to provide both emergency and neurocritical care at the QEII Health Sciences Centre in 2017, joining the Dalhousie Faculty of Medicine as part of both the Department of Emergency Medicine and the Department of Critical Care. Dr. Murphy has already completed a residency in emergency medicine and is in the final year of the two-year fellowship in critical care at Dalhousie.

Her interest in neurocritical care stems from a family member’s experience with a brain injury, which spurred a desire to provide care for people experiencing brain trauma and conditions such as hemorrhage and aneurysm.

“Patients who have incurred brain trauma are some of the most vulnerable in the ICU, and there isn’t a lot of evidence on how to achieve the best patient outcomes. I want the training and opportunity to contribute to our understanding of neurocritical care, and bring this expertise to patients and our critical care team in Halifax.”

Dr. Laurel Murphy

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teach Dr. Laurel Murphy cont’d.

Dr. Murphy began the five-month immersive neurocritical care fellowship in September 2016 and will rejoin the critical care team in Halifax as a fellow upon completion. This is just one of the beneficial detours she has taken during her medical training. The flexibility offered by the Dalhousie postgraduate programs, including critical care, allowed her and her husband to start their family. They now have two young children.

“Our home is in Halifax, and though the city and Dalhousie are considered small by some standards, the two have offered exceptional opportunities for me. In the emergency medicine and critical care postgraduate programs, I quickly learned faculty are very supportive and genuinely want us [residents and fellows] to succeed.”

When Dr. Murphy brings her success back to Halifax, she will add to the critical care expertise available to patients and families at the QEII and contribute to the education of medical students and residents at Dalhousie.

The Department of Critical Care admits one fellow annually to its two-year subspecialty training program. Applicants must have completed training in a medical specialty (anesthesia, emergency medicine, surgery or internal medicine) prior to admission. While in the critical care subspecialty program, fellows participate in a range of academic activities, including teaching Dalhousie medical students and residents. Dr. Murphy will complete the Dalhousie critical care program in 2017 while also working as an emergency medicine staff physician at the QEII.

Critical care education 101 The Department of Critical Care is an academic department whose members strive to increase understanding and knowledge of critical care through education and research.

What follows is a summary of Dalhousie critical care education, including who learns and teaches critical care medicine, how faculty learn to teach critical care and what’s new in critical care education at Dalhousie.

Who learns critical care medicine?

■ Medical students Students in all four years of Dalhousie Medical School gain some knowledge and experience with critical care. First- and second-year medical students can observe, or shadow, faculty members in the ICU. Critical care faculty are some of the most popular and awarded faculty at Dalhousie.

Students in their third and fourth years of medical school (clinical clerks) can choose to rotate through the ICUs under the direction of critical care faculty. As clinical clerks, they more actively participate in critical care. Students also participate in two- or three-week sessions to enhance their clerkship years, which are all based on some aspect of critical care.

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■ Staff physicians

Dr. Babar Haroon

■ Residents Residents in disciplines including surgery, emergency medicine, internal medicine, radiology and anesthesia participate in rotations in the Department of Critical Care. The rotations are generally four weeks and involve residents actively participating in critical care under the direction and supervision of critical care faculty. The breadth and depth of teaching and learning in each rotation and the number of rotations a resident is required to undertake varies by specialty. The curriculum of each specialty follows the requirements of the Royal College of Physicians and Surgeons of Canada (RCPSC).

“Having residents from other disciplines participate in critical care helps meet many curriculum outcomes, but it primarily enables residents to recognize when a patient is very ill and requires immediate actions. We also teach residents what those immediate actions may be and when to call for help,” says Dr. Babar Haroon, director of the critical care subspecialty training program.

■ Fellows

The Department of Critical Care is home to exceptionally knowledgeable intensivists who are accomplished teachers and researchers. As part of an academic department, faculty actively seek opportunities to share their knowledge and expertise with their colleagues in other disciplines and in critical care across Nova Scotia and Canada. They provide presentations on the national stage, participate in workshops or seminars for physicians in Nova Scotia and the Maritimes, routinely present on various topics related to critical care for colleagues at the QEII Health Sciences Centre, and offer simulation education to practise running complex scenarios at the QEII. ■ Critical care nurses The critical care units are home to nurses with specialized training in critical care. They are highly skilled professionals with a focus on providing the best possible care to every patient. They regularly present at national conferences to share knowledge and quality improvement processes they have spearheaded in the units to help build capacity within nursing and improve care across Canada.

“The goal of all educational activity by the entire critical care team is to strengthen critical care medicine to improve patient outcomes. Exceptional critical care education is directly linked to better care,” says Dr. Haroon.

The Department of Critical Care admits one fellow annually to its two-year subspecialty training program. Fellows must have completed training in a medical specialty (anesthesia, emergency medicine, surgery or internal medicine) prior to admission. Upon successful completion of the immersive critical care subspecialty program and RCPSC exams, fellows graduate as intensivists.

Dalhousie critical care graduates gain experience and training that enables them to provide exceptional critical care in all types of ICUs, and they most often choose to practise in the Maritime provinces.

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teach How many members of the Department of Critical Care teach?

All physician members (13 at the QEII and 9 at DGH) of the Department of Critical Care teach as faculty of Dalhousie Medical School. They spend hundreds of hours each year teaching medical students, residents, fellows and staff physicians inside and outside of the ICU. What do critical care faculty teach?

Faculty in the Department of Critical Care teach everything from the basics of what critical care is and when it is needed, to the specifics of fluid and volume resuscitation. They teach and mentor learners to develop decision-making and communication skills, especially in instances when patients are very ill and need immediate treatment, which are indicative of critical care medicine. Faculty also impart the basics and complexities of medical equipment, including monitors, ventilators and ultrasound, which are used in the delivery of critical care.

Faculty use simulation to teach critical care fellows, residents, nurses and other health care providers in many disciplines how best to attend to unresponsive patients and how to work as a team when doing so. Many critical care faculty are also researchers. Part of their role is to help residents and fellows to participate in or lead research studies that increase understanding and knowledge of critical care medicine.

How do faculty learn to teach critical care?

Critical care faculty and fellows may participate in teaching workshops and presentations, simulation instructor training, and graduate-level education programs. In keeping with the Department of Critical Care’s commitment to teaching excellence, faculty are encouraged and supported to continually improve their teaching skills and knowledge of best practices in medical education. All Department of Critical Care faculty are recognized teachers and many have received Dalhousie honours for teaching.

What is new with critical care education?

The education portfolio within the Department of Critical Care is focused on three main initiatives that have significant impacts on its educational offerings. A new model of education, competency-based medical education, supported by the Royal College of Physicians and Surgeons of Canada (RCPSC), is rolling out across Canada. Competency-based medical education signals a new era in medical education, where predetermined milestones must be achieved and demonstrated by residents before they can advance.

The Department will fully embed Point of Care Ultrasound into its curriculum, including holding an echocardiogram (echo) workshop in fall 2016, using an echo simulator, and holding echo rounds. Plans are also underway for twice monthly multidisciplinary rounds.

Lastly, the Department is actively recruiting critical care trainees from other countries who would participate in critical training under the direction of faculty members. Upon completion, the trainees would return to their home hospitals to increase their capacity for critical care.

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investigate F O S T E R I N G R E S E A R C H A N D I N N O V AT I O N I N C R I T I C A L C A R E In 2015-2016, Department of Critical Care members led or participated in eight multi-centre studies and trials to improve the care of critically ill patients, and published 29 articles, advancing the understanding of critical care, its delivery and its outcomes. The Department is home to two senior researchers, Dr. Rick Hall, professor, and Dr. Rob Green, professor, and recently recruited investigator Dr. Osama Loubani, assistant professor. Several other department members are actively involved in clinical research also.

Areas of study include: •

critical care pharmacology

•

resuscitation and severe sepsis

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acute lung injury and acute respiratory distress syndrome

•

rates of, barriers to and facilitating factors for mobilization

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influenza

•

post-intubation outcomes

Dr. Rick Hall: Career dedication Dr. Rick Hall is credited with establishing a critical care research portfolio at Dalhousie University. He is the most senior researcher in the Department of Critical Care and is one of Canada’s most well respected researchers in critical care and in anesthesia, a discipline to which he has a joint appointment at Dalhousie. As his long-time research coordinator, Lisa Julien, says, “When Rick talks, people listen.”

Dr. Hall was the first to lead a multi-centre clinical trial in the ICU at the QEII Health Sciences Centre, is a founding member of the Canadian Critical Care Trials Group, the most successful critical care trials network in the world, and is a founder of the Canadian Perioperative Anesthesia Clinical Trials (PACT) group. Dr. Hall also spent decades as the chair of the QEII’s research ethics board.

In his 35+ year career, Dr. Hall has overcome considerable professional and personal challenges to advance the understanding of critical care and anesthesia, particularly the many effects of inflammation and infection. His background in pharmacology has meant that he has been involved in most research on drugs used in critical care medicine in Canada.

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Dr. Rick Hall Receives National Recognition for Research Dr. Rick Hall has quietly and methodically improved anesthesia and critical care and safety in Canada and beyond for more than 25 years. He was recently named the 2016 recipient of the Canadian Anesthesiologists’ Society Research Recognition Award for his efforts. The award is the society’s most prestigious research honour.

Dr. Rick Hall cont’d.

“In the early years of my work, clinical research was undervalued,” says Dr. Hall. “It was poorly resourced and poorly supported by hospitals and health centres, even those with strong academic mandates. As a result, I devoted a lot of personal time to my research. It has been a great pleasure to see that through. Thankfully things are improving.”

The thrill he gets from publishing his work is what has held Dr. Hall’s commitment to research. “I like to see my name in print. It signals the culmination of a huge amount of work. To think I’ve also made some contribution to the advancement of science along the way is pretty great.”

Dr. Hall has been mentored by some of Dalhousie University’s exceptional faculty, including the late Dr. Emerson Moffitt, professor emeritus (anesthesia), and Dr. Jean Gray, professor emeritus (pharmacology). He has also had the pleasure of mentoring many learners and colleagues, including Dr. Rob Green and Dr. Osama Loubani in the Department of Critical Care.

Dr. Hall has spent much of 2015-2016 attempting to wrap up his research program in preparation for retirement in 2017.

Dr. Loubani has been working closely with Dr. Hall and with Ms. Julien to help him build an excellent foundation in clinical research and to ensure some of Dr. Hall’s unfinished studies will continue.

As for what Dr. Hall wants Dr. Loubani and others to hold true: “Research is the engine that will drive the health system forward, creating better understanding and improving care.”

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Before graduating with an MD, Dr. Hall conducted a prospective study of the influence of influenza vaccination on theophylline pharmacokinetics under the supervision of Dr. Ken Renton at Dalhousie. The results of the study, published in the Canadian Medical Association Journal in 1980, led to a hypothesis that the systemic inflammatory response to infection alters drug metabolism— the crux of Dr. Hall’s career-long program of related basic and clinical research.

After accepting a position at Dalhousie as assistant professor of anesthesia and pharmacology in 1987, Dr. Hall began to merge his interests in the influence of inflammation on drug response with cardiac anesthesia.

He has since conducted studies examining almost every facet of the practice of cardiac anesthesia.

Dr. Hall’s work has so far resulted in more than 56 peer-reviewed research funding awards as principal or co-investigator, 200 publications and 180 invited presentations. And he has helped change the research landscape in Canada as a founding member of the Canadian Critical Care Clinical Trials Group, one of the leading clinical trials collaborations in the world, and the Canadian Perioperative Anesthesia Clinical Trials Group (PACT).

Dr. Hall is a professor of anesthesia, critical care and pharmacology, a world expert in cardiovascular intensive care and cardiac anesthesia, and a Canadian authority on research ethics, particularly as it relates to end-of-life care.

investigate Dr. Rob Green: Senior research leadership in critical care Dr. Rob Green maintains a research portfolio focused on the resuscitation of critically ill patients in the emergency department, ICU and trauma environment. He is the primary investigator for a multi-centre investigation of the incidence and associated outcomes of patients who develop postintubation hemodynamic instability. This multi-faceted research accounted for three publications in 2015-2016.

Dr. Green has more than 100 publications to his credit and is currently involved in more than 15 studies of varying size, scope and status, including: •

transfusion strategies in traumatic brain injury

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post-intubation hypotension in trauma patients

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an investigation of the health and economic outcomes of alcohol-related traumatic brain injury in Nova Scotia

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alcohol-related major trauma recidivism in Nova Scotia: a retrospective analysis

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factors associated with adverse outcomes in adult trauma patients in Nova Scotia

Dr. Osama Loubani: Signalling the future of critical care research Dr. Osama Loubani joined the Department of Critical Care in July 2014 after completing his residency in critical care with the department. As part of his residency, Dr. Loubani worked with Dr. Rob Green on several research projects, cementing his interest in research. Dr. Loubani’s primary interest is in the use of vasopressors, drugs to increase blood pressure. Specifically, he is exploring whether the currently accepted administration of vasopressors via central line is actually more advantageous—results in better outcomes for patients—than administration via peripheral nerve.

In addition to his work with Dr. Green, Dr. Loubani has been working with Dr. Rick Hall in preparation of carrying forward Dr. Hall’s research studies upon his retirement in 2017.

With Dr. Rick Hall’s pending retirement, Dr. Green has assumed a lead role in cultivating research in the Department of Critical Care. In this role and with the support of the Department, Dr. Green aims to help balance research in the Department among investigator-initiated studies, critical care clinical trials and industry-sponsored research. “We intend to support Dr. Loubani and other critical care members who may want to pursue some research through mentorship and creating appropriate infrastructure. The recent hiring of a research associate in the department demonstrates a commitment to grow and strengthen critical care research.”

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appendix A P P E N D I X 1 : M E M B E R S O F T H E D E PA RT M E N T O F C R I T I C A L C A R E

CRITICAL CARE QEII (Victoria General and Halifax Infirmary) Dr. Patrick Ward Department Head/Chief Professor, Critical Care Dr. Stephen Beed, Professor, Critical Care, Anesthesia Site Chief, 3A Med/Surg ICU, Victoria General Medical Advisor, Legacy of Life Dr. Janice Chisholm Associate Professor, Critical Care, Anesthesia

Dr. Jennifer Hancock Associate Professor, Critical Care, Internal Medicine

Dr. Volker Eichhorn Assistant Professor, Critical Care, Anesthesia Medical Co-Lead, Critical Care Quality Improvement/Assurance Program

Dr. Babar Haroon Assistant Professor, Critical Care, Internal Medicine Program Director, Royal College Training Program, Critical Care

Dr. William Gallacher Professor, Critical Care, Anesthesia

Dr. Osama Loubani Assistant Professor, Critical Care, Emergency Medicine

Dr. Robert Green Professor, Critical Care, Emergency Medicine Medical Director, Trauma Nova Scotia

Dr. Sarah McMullen (Also works with the DGH ICU) Assistant Professor, Critical Care, Internal Medicine Medical Lead, Critical Care Quality Improvement/Assurance Program

Dr. Richard Hall Professor, Critical Care, Pharmacology, Anesthesia Site Chief, 5.2, Med/Surg/Neuro ICU, Halifax Infirmary

Dr. Sam Minor Associate Professor, Critical Care, General Surgery Undergraduate/Postgraduate Education Coordinator Dr. Tobias Witter Assistant Professor, Critical Care, Anesthesia Medical Director, Respiratory Therapy

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A P P E N D I X 1 : M E M B E R S O F T H E D E PA RT M E N T O F C R I T I C A L C A R E CRITICAL CARE (Dartmouth General Hospital)

ICU SUBSPECIALTY TRAINEES

Dr. Laurel Murphy Critical Care, Emergency Medicine

Dr. Jorin LindenSmith Site Chief, DGH ICU Assistant Professor, Critical Care, Medicine

Dr. Emily Rowsell Critical Care, Surgery

Dr. Paul Charlebois Assistant Professor, Critical Care, Medicine

Dr. Edmund Tan Critical Care, Anesthesia

Dr. Jackie Flemming Assistant Professor, Critical Care, Medicine Dr. Rafal Kasina Assistant Professor, Critical Care, Medicine

INTENSIVE CARE UNITS

Dr. Cliff McCarville Assistant Professor, Critical Care, Medicine

Cynthia Isenor Health Services Manager of MSNICU 5.2 HI Site

Dr. Paul Mears Assistant Professor, Critical Care, Medicine

Patricia Daley Health Services Manager of MSICU 3A VG Site

Dr. Duane Sheppard Assistant Professor, Critical Care, Medicine

Sharon Ingram Health Services Manager of DGH ICU

Dr. Colin VanZoost Assistant Professor, Critical Care, Medicine

Lisa Julien Critical Care Research Coordinator

Dr. Jason Yung Assistant Professor, Critical Care, Medicine

Nelofar Kureshi Research Associate

CRITICAL CARE QEII (Administrative Office)

Karen Webb-Anderson Critical Care Quality Leader Dr. Meghan MacKenzie Critical Care PharmD

Kim Rhymes Manager/Administrator Kristen Griffiths Administrative Assistant Steph Berntson Subspecialty Education Administrator

CRITICAL CARE DGH (Administrative Office) Tanya Ferguson Administrative Assistant

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A P P E N D I X 2 : I C U D ATA B Y S I T E 2013 - 2014

5.2 Halifax Infirmary

3A Victoria General

Dartmouth General

Admissions/Occurrences

814 Visits

577 Visits

521 Visits

Mortality Hospital

22.0%

16.6%

10.7%

Mortality ICU

14.9%

11.3%

6.3%

Average LOS ICU

4.4 Days

4.1 days

3.9 Days

ALOS Hospital

23.7 Days

25.9 Days

11.7 Days

Average ELOS

23.0 Days

23.9 Days

9.5 Days

Conservable Days

510.9 Days

1056.6 days

1117.9 Days

Total Readmission to ICU

5.5%

7.8%

1.5%

Readmission under 48 hours

2.46%

5.0%

0.77%

Readmission over 48 hours

3.07%

2.8%

0.77%

2014 - 2015

5.2 Halifax Infirmary

3A Victoria General

Dartmouth General

Admissions/Occurrences

786 Visits

562 Visits

535 Visits

Mortality Hospital

23.2%

18.5%

14.2%

Mortality ICU

15.6%

13.5%

10.5%

Average LOS ICU

4.3 Days

4.3 Days

4.2 Days

ALOS Hospital

24.0 Days

23.6 Days

10.3 Days

Average ELOS

24.2 Days

26.6 Days

9.4 Days

Conservable Days

-209.9 Days

-1563.5 Days

447.2 Days

Total Readmission to ICU

5.0%

6.8%

1.1%

Readmission under 48 hours

2.04%

2.8%

0.37%

Readmission over 48 hours

2.93%

3.9%

0.75%

2015 - 2016

5.2 Halifax Infirmary

3A Victoria General

Dartmouth General

Admissions/Occurrences

795 Visits

475 Visits

527 Visits

Mortality Hospital

18.9%

15.2%

10.25%

Mortality ICU

13.0%

10.7%

7.97%

Average LOS ICU

4.2 Days

4.5 Days

4.22 Days

ALOS Hospital

23.6 Days

26.7 Days

8.4 Days

Average ELOS

23.0 Days

23.9 Days

8.9 Days

Conservable Days

461.1 Days

1164.1 Days

-259.5 Days

Total Readmission to ICU

6.7%

8.8%

0.76%

Readmission under 48 hours

3.14%

2.1%

0.19%

Readmission over 48 hours

3.52%

6.7%

0.57%

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A P P E N D I X 3 : I C U P AT I E N T S ( 3 A , 5 . 2 , D G H I C U ) B Y R E S I D E N C E Z O N E % of Total Cases by Zone in ICU 3A

% of Total Cases by Zone in DGH ICU

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APPENDIX 4: RESEARCH PROJECTS 2015-2016 TOTAL: $133,321 (April 2015 – March 2016)

$ amounts listed are amounts received during fiscal time period

GRANT FUNDED Early determination of neurological prognosis in ICU patients with severe traumatic brain injury: TBI prognosis multi-center prospective study Start date: Completion date: Funder: Total Funding amount: Enrollment: Principal Investigator:

April 2013 September 2016 CIHR $39,878 45 Dr. Robert Green

Re-evaluating the inhibition of stress erosions: Gastrointestinal bleeding prophylaxis in ICU (REVISE): A feasibility pilot trial Start date: Completion date: Funder: Total Funding amount: Enrollment numbers: Principal Investigator:

January 2015 January 2016 Capital Health Research Fund $15,000 12 Dr. Richard Hall

Bacteremia antibiotic length actually needed for clinical effectiveness (BALANCE) Start date: Completion date: Funder:

March 2015 Ongoing Ministry of Health and Long-Term Care Academic Health Sciences Alternative Funding Plan Innovation Fund Award Total Funding amount: $8,000 Enrollment numbers: 4 Principal Investigator: Dr. Richard Hall

INDUSTRY FUNDED A randomized, double blind, placebo controlled, phase 3 study to assess the safety and efficacy of ART-123 in subjects with severe sepsis and coagulopathy (#3-001) Start date: Completion date: Funder: Total Funding amount: Enrollment: Principal Investigator:

A phase 3 randomized double-blind study comparing TR-701-FA and linezolid in ventilated gram-positive nosocomial pneumonia Start date: Completion date: Funder: Total Funding amount: Enrollment numbers: Principal Investigator:

July 2014 April 2016 Trius Therapeutics $2,447 0 Dr. Richard Hall

Treatment of septic shock by inhibiting autodigestion and preserving gut integrity with Enteric LB1148 (SSAIL study) Start date: Completion date: Funder: Total Funding amount: Enrollment numbers: Principal Investigator:

September 2015 February 2016 Leading BioSciences $12,370 0 Dr. Richard Hall

Promotion of regular oesophageal motility to prevent regurgitation and enhance nutrition intake in long-stay ICU patients: A multi-center, sham-controlled, randomized trial.

The PROPEL Study Start date: Completion date: Funder: Total Funding amount: Enrollment numbers: Principal Investigator:

July 2014 Ongoing E-Motion Medical Ltd. $6,630 7 Dr. Richard Hall

A phase 3, placebo-controlled, randomized, double-blind, multi-center study of LJPC-501 in patients with catecholamine-resistant hypotension (CRH) Start date: Completion date: Funder: Total Funding amount: Enrollment numbers: Principal Investigator:

July 2014 February 2016 LaJolla $0 0 Dr. Richard Hall

December 2012 Ongoing Asahi Kasei Pharma America Corporation $48,996 3 Dr. Richard Hall

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A P P E N D I X 5 : PEER-REVIEWED PUBLICATIONS, PRESENTATIONS, ABSTRACTS 2015-2016 lines for the use of targeted temperature management after cardiac arrest: A joint statement from The Canadian Critical Care Society, Canadian Neurocritical Care Society, and the Canadian Critical Care Trials Group. Resuscitation. 98: 48-63.

PUBLICATIONS Vincent J-L, Marshall JC, Dellinger P, Simonson SG, Guntupalli K, Levy MM, Singer M, Malik R, Hall R. Results from the phase II/III oral talactoferrin in severe sepsis trial. Critical Care Medicine 2015; 43:1832-8. www.ccmjournal.org. DOI: 10.1097/CCM.00000000 00001090. PMID: 26010687 Wang Y, Goralski K, Roberts D, Landry K, Issa M, Lekha S, Julien L, Wood J, Hall R. Does surgically-induced peripheral inflammation affect the distribution of the P-glycoprotein substrate morphine across the human blood-brain barrier? Clinical Pharmacology & Therapeutics 2015 (submitted July 2015).

Hall R, Turgeon AF. Palliative care in the neurologic ICU – Are we there yet? Crit Care Med 2015 (Sept) 43(9):2033-4. PMID: 26274714 DOI: 1097/CCM.0000000000001176 Cape D, Fox-Robichaud A, Turgeon AF, Seely A, Hall R, Burns K, Singal RK, Dodek P, Bagshaw S, Sibbald R, Downar J. The impact of the Rasouli decision: A survey of Canadian intensivists. J Med Ethics (BMJ) 2016; 42:180-5 (published online 30 November 2015). PMID: 26621856; DOI: 10.l136/medethics-2015-102856 Daneman N, Dodek P, Marshall J, Bagshaw S, Hall R, Lauzier F, Lamontagne F, Martin C, McIntyre L, Muscedere J, Stelfox T, Kumar A, Reynolds S, Cook D. Duration of antimicrobial treatment for bacteremia in Canadian critically ill patients. Critical Care Medicine 2016 (February); 44(2): 256-64. PMID: 26496448; DOI: 10.1097/CCM. 000000000000 1393 Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care.

2015 Jun;30(3):653.e9-17

Cornish M, Butler MB, Green RS. (2016). Predictors of poor outcomes in critically ill adults with hematologic malignancy. Canadian Respiratory Journal. 2016(9431385) Green RS, Butler MB, Hicks SD, Erdogan M. (2016). Effect of hydroxyethyl starch on outcomes in high-risk vascular surgery patients: A retrospective analysis. Journal of Cardiothoracic and Vascular Anesthesia. Feb 12: pii: S1053-0770(16)0.

Stiell IG, Artz JD, Lang ES, Sherbino J, Morrison LJ, Christenson J, Perry JJ, Topping C, Woods R, Green RS, Lim R, Magee K, Foote J, Meckler G, Mensour M, Field S, Cheung B, Kuuskne M, Ducharme J, Klein V, McEwen J. (2016). An environmental scan of academic emergency medicine at the 17 Canadian medical schools: Why does this matter to emergency physicians? Canadian Journal of Emergency Medicine.

Green RS, Fergusson DA, Turgeon AF, McIntyre LA, Kovacs GJ, Griesdale DE, Zarychanski R, Butler MB, Kureshi N, Erdogan M, on behalf of the Canadian Critical Care Trials Group (CCCTG). (2016).

Device and medication preferences of Canadian physicians for endotracheal intubation in critically ill patients. Canadian Journal of Emergency Medicine.

Nunn J, Erdogan M, Green RS. (2016). The prevalence of alcoholrelated trauma recidivism: A systematic review. Injury. 47(3): 551-8.

Vaillancourt C, Rowe BH, Artz JD, Green RS, Émond M, Thiruganasambandamoorthy V, Innes G, Perry JJ, Calder LA, Stiell IG. (2015). CAEP 2014 academic symposium: "How to make research succeed in your department: How to fund your research program".

Canadian Journal of Emergency Medicine. 17(4): 453-61.

Djogovic D, MacDonald S, Wensel A, et al. Vasopressor and inotrope use in Canadian emergency departments: Evidence-based consensus guidelines. CJEM 2015; 17(1):1–2

Green RS, Turgeon AF, McIntyre LA, Fox-Robichaud AE, Fergusson DA, Doucette S, Butler MB, Erdogan M; Canadian Critical Care Trials Group (CCCTG). (2015). Postintubation hypotension in intensive care unit patients: A multi-center cohort study. Journal of Critical Care.

Engels PT, Erdogan M, Widder SL, Butler MB, Kureshi N, Martin K, Green RS. (2016). Use of IO devices in trauma: A survey of trauma practitioners in Canada, Australia, and New Zealand. Canadian Journal of Surgery. (Accepted for publication)

Yaffe PB, Green RS, Butler MB, Witter T. (2015). Is admission to the intensive care unit associated with chronic opioid use? A 4-year follow up of intensive care unit survivors. Journal of Intensive Care Medicine.

Green RS, Fergusson DA, Turgeon AF, McIntyre LA, Kovacs GJ, Griesdale DE, Zarychanski R, Butler MB, Kureshi N, Erdogan M, on behalf of the Canadian Critical Care Trials Group (CCCTG). (2016).

Resuscitation prior to emergency endotracheal intubation: Results of a national survey. Western Journal of Emergency Medicine.

Djogovic D, MacDonald S, Wensel A, Green R, Loubani O, Archambault P, Bordeleau S, Messenger D, Szulewski A, Davidow J, Kircher J, Gray S, Smith K, Lee J, Marc Benoit J, Howes D. (2015).

Vasopressor and inotrope use in Canadian emergency departments: Evidence-based consensus guidelines. Canadian Journal of Emergency Medicine. 17(1): 1-2.

Green RS, Travers AH, Cain E, Campbell SG, Jensen JL, Petrie DA, Erdogan M, Patrick G, Patrick W. (2016). Paramedic recognition of sepsis in the prehospital setting: A prospective observational study.

Emergency Medicine International.

Sowers N, Froese P, Erdogan M, Green RS. (2015). Impact of the age of stored blood on trauma patient mortality: A systematic review.

Canadian Journal of Surgery. 58(5): 335-342.

Kuca T, Butler MB, Erdogan M, Green RS. (2016). A comparison of balanced and unbalanced crystalloid solutions in surgery patient outcomes. Anaesthesia Critical Care and Pain Medicine.

Green RS, Butler MB, Campbell S, Erdogan M. (2015). Adverse events and outcomes of procedural sedation and analgesia in major trauma patients. Journal of Emergencies, Trauma and Shock. 8(4): 210-215.

Howes D, Gray SH, Brooks SC, Boyd JG, Djogovic D, Golan E, Green RS, Jacka MJ, Sinuff T, Chaplin T, Smith OM, Owen J, Szulewski A, Murphy L, Irvine S, Jichici D, Muscedere J. (2016). Canadian GuideA6

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Green RS, Butler MB. (2015). Post-intubation hypotension in general anesthesia: A retrospective analysis. Journal of Intensive Care Medicine.

A P P E N D I X 5 : PEER-REVIEWED PUBLICATIONS, PRESENTATIONS, ABSTRACTS 2015-2016 Green RS, Butler MB, Kureshi N, Erdogan M. (2015). A retrospective evaluation of pediatric major trauma related to sport and recreational activities in Nova Scotia. Canadian Journal of Emergency Medicine.

Nunn J, Erdogan M, Green RS. (December 2015). The prevalence of alcohol-related trauma recidivism: A systematic review. London Trauma Conference. London Trauma Conference.

Artz J, Erdogan M, Green RS. (2015). A national survey on small research grants and the scholarly productivity of emergency medicine physicians in Canada. Research Evaluation.

Cornish M, Butler MB, Green RS. (October 2015). Predictors of poor outcomes in critically ill patients with hematologic malignancy.

European Society of Intensive Care Medicine Annual Congress.

Hurley K, Magee M, Green RS. (2015). Aminophylline for bradyasystolic cardiac arrest in adults. Cochrane Database Systematic Reviews. 11(CD006781): 1-41.

Green RS, Butler MB, Hicks SD, Erdogan M. (October 2015). Effect of hydroxyethyl starches and crystalloid fluids on mortality and need for dialysis in vascular surgery patients. European Society of Intensive Care Medicine Annual Congress.

Fowler RA, Abdelmalik P, Wood G, Foster D, Gibney N, Bandrauk N, Turgeon AF, Lamontagne F, Kumar A, Zarychanski R, Green RS, Bagshaw SM, Stelfox HT, Foster R, Dodek P, Shaw S, Granton J, Lawless B, Hill A, Rose L, Adhikari NK, Scales DC, Cook DJ, Marshall JC, Martin C, Jouvet P; Canadian Critical Care Trials Group; Canadian ICU Capacity Group. (2015). Critical care capacity in Canada: Results of a national cross-sectional study. Critical Care. 19(133): 1-8.

Yaffe P, Green RS, Butler MB, Witter T. (October 2015). Is ICU admission associated with chronic narcotic use? A 7-year population based analysis. European Society of Intensive Care Medicine Annual Congress.

Green RS, Kureshi N, Erdogan M. (2015). Legal consequences for alcohol-impaired drivers injured in motor vehicle collisions: A systematic review. Accident Analysis & Prevention. 80: 106-16.

Green RS, Turgeon AF, McIntyre LA, Fox-Robichaud AE, Fergusson DA, Doucette S, Butler MB, Erdogan M. (June 2015). Post-intubation hemodynamic instability in intensive care unit patients: A multi-center study. Canadian Association of Emergency Physicians Annual Meeting.

ABSTRACTS

Green RS, Kureshi N, Erdogan M. (June 2015). Legal consequences for alcohol-impaired drivers injured in motor vehicle collisions: A systematic review. Canadian Association of Emergency Physicians Annual Meeting.

Hall R. The effect of inadequate initial antimicrobial treatment on mortality in critically ill patients with bloodstream infections.

IDWeek Abstract #52296. Submitted May 2015.

Shears M, Al-Hazzami W, Cook D, Marshall J, Muscedere J, Hall R, Guyatt G, English S, Dodek P, Lauzier F, Kanji S, Duffett M, Barletta J, Alshumrani MA. Survey of medications for the inhibition of stress erosions (SURMISE): A Canadian survey. Canadian Critical Care Forum (CCCF). ID # 06330000 70. Accepted October 2015.

Green RS, Butler MB, Kureshi N, Erdogan M. (June 2015). A retrospective evaluation of pediatric major trauma related to sport and recreational activities in Nova Scotia. Atlantic Collaborative on Injury Prevention Annual Meeting, Halifax, Canada.

Green RS, Kureshi N, Erdogan M. (June 2015). Legal consequences for alcohol-impaired drivers injured in motor vehicle collisions: A systematic review. Atlantic Collaborative on Injury Prevention Annual Meeting, Halifax, Canada.

Green RS, Butler MB, Kureshi N, Erdogan M. (June 2015). A characterization of adult sport and recreation-related major trauma in Nova Scotia, 2000-2013. Atlantic Collaborative on Injury Prevention Annual Meeting, Halifax, Canada.

Minor S, Erdogan M, Hartlen K, Green RS. (December 2015). Development of a hospital-wide program for simulation-based training in trauma care and management. London Trauma Conference.

Green RS, Fergusson D, Turgeon A, McIntyre L, Kovacs G, Griesdale D, Zarychanski R, Butler MB, Kureshi N, Erdogan M. (December 2015). A national survey of the resuscitation practices of Canadian physicians prior to emergent endotracheal intubation in trauma patients. London Trauma Conference.

Artz J, Erdogan M, Green RS. (June 2015). Do small grants make a difference in the careers of researchers? Canadian Association of Emergency Physicians Annual Meeting.

Green RS, Fergusson D, Turgeon A, McIntyre L, Kovacs G, Griesdale D, Zarychanski R, Butler MB, Kureshi N, Erdogan M. (June 2015).

Treatment of post-intubation hemodynamic instability by Canadian emergency medicine and critical care medicine physicians. Canadian Association of Emergency Physicians Annual Meeting.

Artz J, Erdogan M, Green RS. (June 2015). Demographics of CAEP grant award winners. Canadian Association of Emergency Physicians Annual Meeting.

Green RS, Fergusson D, Turgeon A, McIntyre L, Kovacs G, Griesdale D, Zarychanski R, Butler MB, Kureshi N, Erdogan M. (June 2015).

Emergent endotracheal intubation: Medications and device choices

by Canadian resuscitation physicians. Canadian Association of Emergency Physicians Annual Meeting.

Engels P, Erdogan M, Widder S, Butler M, Kureshi N, Martin K, Green RS. (June 2015). Use of intraosseous devices in trauma: A survey of trauma practitioners in Canada, Australia, and New Zealand. Canadian Association of Emergency Physicians Annual Meeting.

Green RS, Fergusson D, Turgeon A, McIntyre L, Kovacs G, Griesdale D, Zarychanski R, Butler MB, Kureshi N, Erdogan M. (June 2015).

Pre-intubation resuscitation by Canadian physicians: Results of a national survey. Canadian Association of Emergency Physicians Annual Meeting.

Green RS, Butler MB, Kureshi N, Erdogan M. (June 2015). A characterization of adult sport-related major trauma in Nova Scotia, 20002013. Canadian Association of Emergency Physicians Annual Meeting.

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A P P E N D I X 5 : PEER-REVIEWED PUBLICATIONS, PRESENTATIONS, ABSTRACTS 2015-2016 Abstracts (cont’d.)

Green RS, Butler MB, Kureshi N, Erdogan M. (April 2015). A characterization of major adult sport-related trauma in Nova Scotia, 2000-2013. Trauma Association of Canada Annual Meeting.

Green RS, Fergusson D, Turgeon A, McIntyre L, Kovacs G, Griesdale D, Zarychanski R, Butler MB, Kureshi N, Erdogan M. (April 2015).

Pre-intubation resuscitation by Canadian physicians: Results of a national survey. Trauma Association of Canada Annual Meeting.

Hayre J, Rouse C, French J, Watson I, Sealy B, Erdogan M, Green RS, Fraser J, Atkinson P. (April 2015). Traumatic tale of two cities, part one: Does being treated by different EMS affect outcomes in trauma patients destined for transport to level one trauma centres in Halifax and Saint John? Trauma Association of Canada Annual Meeting.

Green RS, Fergusson D, Turgeon A, McIntyre L, Kovacs G, Griesdale D, Zarychanski R, Butler MB, Kureshi N, Erdogan M. (April 2015).

Emergent endotracheal intubation: Medications and device choices

by Canadian resuscitation physicians. Trauma Association of Canada Annual Meeting.

Rouse C, Hayre J, French J, Watson I, Sealy B, Erdogan M, Green RS, Fraser J, Atkinson P. (April 2015). Traumatic tale of two cities, part two: Does being treated by different hospitals affect outcome in trauma patients destined for transport to level one trauma centres in Halifax and Saint John? Trauma Association of Canada Annual Meeting.

Green RS, Kureshi N, Erdogan M. (April 2015). Legal consequences for alcohol-impaired drivers involved in motor vehicle collisions: A systematic review. Trauma Association of Canada Annual Meeting.

Green RS, Butler MB, Kureshi N, Erdogan M. (April 2015). Is hockey the most dangerous pediatric sport? An evaluation of pediatric sport-related injuries treated in Nova Scotia. Trauma Association of Canada Annual Meeting.

Engels P, Erdogan M, Widder S, Butler M, Kureshi N, Martin K, Green RS. (April 2015). Use of IO devices in trauma: A survey of trauma practitioners in Canada, Australia, and New Zealand. Trauma Association of Canada Annual Meeting.

Sowers N, Froese P, Erdogan M, Green RS. (April 2015). Impact of the age of stored blood on trauma patient mortality: A systematic review. Trauma Association of Canada Annual Meeting.

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