UBC Faculty Research and Publications

Critical care capacity in Canada: results of a national cross-sectional study Fowler, Robert A; Abdelmalik, Philip; Wood, Gordon; Foster, Denise; Gibney, Noel; Bandrauk, Natalie; Turgeon, Alexis F; Lamontagne, François; Kumar, Anand; Zarychanski, Ryan; Green, Rob; Bagshaw, Sean M; Stelfox, Henry T; Foster, Ryan; Dodek, Peter; Shaw, Susan; Granton, John; Lawless, Bernard; Hill, Andrea; Rose, Louise; Adhikari, Neill K; Scales, Damon C; Cook, Deborah J; Marshall, John C; Martin, Claudio; Jouvet, Philippe Apr 1, 2015

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RESEARCHCritical care capacity in Cate0,aworCaFowler et al. Critical Care  (2015) 19:133 DOI 10.1186/s13054-015-0852-6specific resources. Moreover, because critical care servicesAvenue, Room D138, Toronto, Ontario M4N 3M5, CanadaFull list of author information is available at the end of the articleIntroductionICUs provide life-supporting treatments to critically illpatients. ICU resources are limited and costly in Canadianhospitals. Clinicians must consider the possible benefitsof admission to ICU, and hospital administrators mustcoordinate the provision of procedures and surgeriesrequiring critical care with existing capacity [1,2]. Duringperiods of increased demand for ICU resources, such asduring infectious outbreaks or pandemics, it canbe difficult to match available resources to clinicaldemands [3-5], resulting in the potential for rationingof ICU care [6].There is substantial global variation in the capacity toprovide critical care [7]. Previous estimates using nationalhealth administrative data indicate that Canada hasfar fewer ICU beds per capita than the United States,but similar numbers of ICU beds to those in manyWestern European nations [8]. Because healthcare is aprovincial portfolio in Canada, differences in provincialpriorities may translate to differences in availability of* Correspondence: rob.fowler@sunnybrook.ca1Interdepartmental Division of Critical Care Medicine and Department ofMedicine, University of Toronto, Toronto, Canada2Department of Critical Care Medicine, Sunnybrook Hospital, 2075 BayviewAbstractIntroduction: Intensive Care Units (ICUs) provide life-supporting treatment; however, resources are limited, sodemand may exceed supply in the event of pandemics, environmental disasters, or in the context of an agingpopulation. We hypothesized that comprehensive national data on ICU resources would permit a betterunderstanding of regional differences in system capacity.Methods: After the 2009–2010 Influenza A (H1N1) pandemic, the Canadian Critical Care Trials Group surveyed allacute care hospitals in Canada to assess ICU capacity. Using a structured survey tool administered to physicians,respiratory therapists and nurses, we determined the number of ICU beds, ventilators, and the ability to providespecialized support for respiratory failure.Results: We identified 286 hospitals with 3170 ICU beds and 4982 mechanical ventilators for critically ill patients.Twenty-two hospitals had an ICU that routinely cared for children; 15 had dedicated pediatric ICUs. Per 100,000population, there was substantial variability in provincial capacity, with a mean of 0.9 hospitals with ICUs (provincialrange 0.4-2.8), 10 ICU beds capable of providing mechanical ventilation (provincial range 6–19), and 15 invasivemechanical ventilators (provincial range 10–24). There was only moderate correlation between ventilation capacityand population size (coefficient of determination (R2) = 0.771).Conclusion: ICU resources vary widely across Canadian provinces, and during times of increased demand, mayresult in geographic differences in the ability to care for critically ill patients. These results highlight the needto evolve inter-jurisdictional resource sharing during periods of substantial increase in demand, and providebackground data for the development of appropriate critical care capacity benchmarks.national cross-sectional sRobert A Fowler1,2*, Philip Abdelmalik3, Gordon Wood4, DAlexis F Turgeon8, François Lamontagne9, Anand Kumar1Henry T Stelfox15, Ryan Foster16, Peter Dodek17, Susan ShLouise Rose21, Neill K Adhikari1,2, Damon C Scales1,2, DebPhilippe Jouvet25 and on behalf of the Canadian Critical© 2015 Fowler et al.; licensee BioMed Central.Commons Attribution License (http://creativecreproduction in any medium, provided the orDedication waiver (http://creativecommons.orunless otherwise stated.Open Accessnada: results of audynise Foster5, Noel Gibney6, Natalie Bandrauk7,Ryan Zarychanski11, Rob Green12,13, Sean M Bagshaw14,18, John Granton19, Bernard Lawless20, Andrea Hill1,2,ah J Cook22, John C Marshall23, Claudio Martin24,re Trials Group and The Canadian ICU Capacity GroupThis is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andiginal work is properly credited. The Creative Commons Public Domaing/publicdomain/zero/1.0/) applies to the data made available in this article,Fowler et al. Critical Care  (2015) 19:133 Page 2 of 8represent one of the most expensive components of thehealthcare system [9], cost is an additional reason forregional differences.Although there have been prior provincial assessments[10-12], our overall national critical care capacity isunknown. Therefore, during the period after the 2009 to2010 influenza A (H1N1) pandemic, the Canadian CriticalCare Trials Group undertook a national survey of all acutecare hospitals to determine the number of critical carebeds and mechanical ventilators, as well as the availabilityof specialized support for respiratory failure in critically illadults and children. We hypothesized that comprehensivenational data on ICU resources would permit a better un-derstanding of regional differences in system capacity inCanada, inform the potential need for inter-jurisdictionalresource sharing during periods of increased national andprovide background data for the development of appropri-ate critical care capacity benchmarks.MethodsQuestionnaire developmentWe developed a capacity survey to tabulate each hospital’scritical care resources using rigorous methodology [13].Questionnaire development consisted of item generationand reduction with input from critical care physicians,nurses, respiratory therapists, clinical researchers, and re-search ethics officers. The questionnaire was subsequentlytested for sensibility and reliability [13]. Final domains in-cluded hospital and respondent characteristics, ICU type,ICU beds, invasive ventilators, availability of specializedsupports for respiratory failure, and a field for qualitativecomments. Recognizing no uniformly accepted definition,we used a sensitive definition of ICU and subsequently de-termined capacity for ongoing invasive mechanical venti-lation in an ICU (that is, not the emergency departmentor post-anesthetic care unit) (see Additional file 1).Respondents and survey completionCanadian Critical Care Trials Group members in each prov-ince were enlisted as local collaborators and site championsin order to identify acute care hospitals and ICUs throughsnowball sampling of colleagues and relevant government-specific and hospital-specific contacts. In some provinces,pre-existing lists had been generated by ministries or depart-ments of health (British Columbia, Alberta, Ontario, NewBrunswick) or critical care societies (Quebec). The searchfor acute care institutions was supplemented by a manualsearch of the Guide to Canadian Healthcare Facilities [14],pre-existing hospital lists of the Public Health Agency ofCanada, Google Maps, and web searches for all hospitals.An ICU physician lead for each hospital was identifiedand contacted by email or telephone. Subsequently, nursingand respiratory therapy leaders were contacted by email ortelephone from pre-existing lists, referral from nearbyinstitutions, or through telephone solicitation directly to thehospital or ICU. The survey was then transmitted by emailor fax for self-administration, or administered via telephoneto physicians, nurses, and/or respiratory therapists. Inhospitals with more than one ICU, additional ICU-specificcontacts were established by subsequent telephone or emailcommunication. In rare cases where no ICU-specific con-tact could be identified, or the leader did not respond (gen-erally for small hospitals that had no geographically distinctICU), we obtained information from an informed clinicianwho was primarily affiliated with another nearby hospital.Respondents were to provide capacity data at the timeof the survey. We attempted to complete data collectionfor each site within a 3-month time frame to limittemporal changes in any measure. In some cases, therewas uncertainty about the number of available ICU bedsbecause of staffing shortages. We asked respondents toanswer based upon how many ICU beds were usuallyavailable for admission should staffing not be a limitation.We attempted to resolve uncertainty about the number ofICUs and bed numbers capable of ventilation throughcommunication with more than one local physician andnurse leader. Respiratory therapy leaders resolved uncer-tainty about numbers of ventilators, and availability ofinhaled nitric oxide, high-frequency oscillatory ventilation,and extracorporeal membrane oxygenation.AnalysesDescriptive statistics are presented as counts, proportions,medians (with range or interquartile range), and means(± standard deviation) as appropriate using Microsoft Excel(Redmond, WA, USA) or SAS (Carey, NC, USA). Wetested the relationship between the number of ICU bedscapable of ventilation and the population by health andcensus regions using the R2 coefficient of determination.Canadian and provincial population census numbers in2009 to 2010 were derived from Statistics Canada censusprojections [15]. Spatial analyses were conducted in collab-oration with the Public Health Agency of Canada in orderto map the locations of hospitals and facilities acrossCanada that had ICU beds with capacity for invasive venti-lation. Moreover, the population within a 40 km servicearea of each of these hospitals was identified using 2006census data [16]. Network analyses using both healthregion and census division service were performed usingCanMap route logistics for road networks and enhancedpoints of interest [17], hydrology data from StatisticsCanada [18], and aerial imagery using Bing™ maps aeria-land ArcGIS 10.0 (ArcView) with the NetworkAnalystextension from ESRIC (see Additional file 1) [19].Confidentiality and ethicsResearch ethics approval for this study was granted bySunnybrook Hospital in April 2009 without the need forFowler et al. Critical Care  (2015) 19:133 Page 3 of 8consent because only institutional data and no individualpatient-related data were collected. Study funders andprovincial governmental officials who provided data hadno role in its analysis or publication.ResultsOverall resourcesWe identified 362 acute care centers in 10 provinces andthree territories. There were 286 hospitals with at leastone self-designated ICU that was capable of providinginvasive mechanical ventilation. ICUs in 22 hospitals haddesignated beds for pediatric patients, and 15 hospitalshad stand-alone pediatric ICUs. The vast majority of ICUs(280, 97.9%) were capable of caring for mixed, medicaland surgical, patient populations. Many ICUs (27, 9.4%)cared for medical, cardiac, or cardiothoracic surgery pa-tients either in isolation or in addition to other critically illpatients. Two ICUs cared exclusively for critically burnedpatients, whereas four routinely cared for some burnedpatients, and three ICUs cared exclusively for neurologic-ally injured or neurosurgical patients.In hospitals with an ICU capable of providing invasivemechanical ventilation there was a total of 4,309 beds, ofwhich 3,170 were specifically designated for mechanicalventilation. Among hospitals with an ICU capable ofproviding invasive mechanical ventilation there was amedian of nine (interquartile range (IQR) 5 to 18) ICUbeds with eight (IQR 3 to 14) beds available for patientswho required invasive mechanical ventilation. There wasa total of 4,982 ventilators capable of providing invasivemechanical ventilation, including ventilators used forpatient transportation (but not those primarily used todeliver inhalational anesthesia during surgery) and a me-dian of 10 (IQR 5 to 23) invasive ventilators per hospital(Table 1). In terms of specialized support for respiratoryfailure, there were 178 high-frequency oscillatory ventila-tors in 72 (25.2%) hospitals that had an ICU capable ofdelivering ventilation, inhaled nitric oxide in 79 (27.6%)hospitals, and extracorporeal membrane oxygenation in 39(13.6%) hospitals. All three supports were available in 32(11.1%) hospitals – all being university teaching centers.Resources across provinces and territoriesThere was substantial variation in capacity to providecritical care among provinces and territories. The mediannumber of ICUs per province was 14 (IQR 10 to 25). Themedian number of ICU beds per province was 122 (IQR110 to 337), and the median number available for mech-anical ventilation was 108 (IQR 97 to 298). The mediannumber of mechanical ventilators per province was 201(IQR 131 to 435). Per 100,000 population in 2009 and2010, there were 0.9 hospitals with ICUs capable ofproviding mechanical ventilation (range 0.4to 2.8), 10 ICUbeds capable of providing mechanical ventilation (range 6to 19), and 15 invasive mechanical ventilators (range 10to 24) (Figure 1, Table 2; Figure S1A in Additional file 1).Resources according to the type of hospitalThere was considerable concentration of ICU resourcesfor mechanical ventilation in teaching hospitals as com-pared with community hospitals. The total number ofteaching and community ICU beds capable of mechan-ical ventilation was 2,027 and 1,143, respectively, with amedian number of 20 (IQR 11 to 31) beds and five (IQR2 to 8) beds, respectively (P <0.001). There was moder-ate correlation between the number of ICU beds capableof mechanical ventilation and the population size forboth health region divisions (R2 = 0.771) and censusdivisions (R2 = 0.809) (Additional file 1).Other qualitative characteristics of ICUsComplementary qualitative data acquired in our surveyshed important insights into critical care capacity inCanada. Some hospitals with small ICUs (that is, fewerthan six ICU beds) commented that despite their capacityfor ongoing ventilation, it was common practice to at-tempt to transfer patients to larger ICUs after a variableperiod of time (many days to a week). Many hospitalscommented that lack of personnel (especially nurses)prevented the full utilization of ICU beds and ventilatorcapacity. In hospitals with more than one ICU, conflictsin admission decision processes prevented optimal ICUbed utilization. For instance, open beds were maintainedin subspecialty ICUs while general ICUs were at orabove capacity.DiscussionWe found substantial variation in the numbers of ICUbeds, as well as the capacity for mechanical ventilationand specialized support for respiratory failure amongICUs in Canada. These findings were not fully explainedby the size of the population. This variation in capacitymay result in differential decision-making about whocan receive ICU support, and which services can besupported in specific hospitals and regions during timesof increased demand [3,5].Prior work by our group using health administrativedata from the Canadian Institute for Health Informationestimated that there were 319 ICUs, 3,388 total adultICU beds (representing 3.4% of all acute care hospitalbeds), and 13.5 ICU beds per 100,000 population [8].However, these data were based on a more liberal defin-ition of critical care beds, did not include data fromQuebec, did not include any interprovincial compari-sons, did not estimate the capacity to treat critically illpatients requiring mechanical ventilation, and were gen-erated one decade ago. Our assessment of ICU beds per100,000 population places Canada near the median ofapatoasiFowler et al. Critical Care  (2015) 19:133 Page 4 of 8high-income and Organization for Economic Co-operationand Development countries, notably above the UnitedKingdom but well below the United States, Germany, andBelgium [8,7,20,21,22].Without knowledge of Canadian critical care capacity,and in the absence of provincial, national, or internationaltargets for population-based critical care resources, therehas been limited national attention to ensuring optimaldistribution among regions. The results of this surveyhighlight expected north–south geography-based capacitytrends, but also an unanticipated apparent east–west gradi-ent with relative increased capacity among the AtlanticTable 1 Number of ICUs and ventilation and oxygenation cRegion Hospitals with ICUswith ventilation capacityICU beds capable ofinvasive ventilationVentilof invNewfoundland 14 98 124Nova Scotia 14 141 191Prince EdwardIsland2 18 22New Brunswick 9 103 113Quebec 87 885 1,197Ontario 84 1,122 2,101Saskatchewan 13 108 235Manitoba 10 93 151Alberta 16 292 373British Columbia 34 304 460Territories 3 6 15Canada 286 3,170 4,982ECMO, extracorporeal membrane oxygenation; iNO, inhaled nitric oxide.Provinces, in comparison with central and western Canada.Some members of our group have previously reportedwide variation in ICU capacity within British Columbiaand an inverse relationship between ICU beds, populationdensity, and population growth, highlighting the potentialfor mismatch in demand and capacity in Canada [11].Some variation in distribution of healthcare services isprobably a consequence of differential regional models ofhealthcare delivery. For example, there are substantial dif-ferences in population density across Canada, with markednorth-to-south increases in density – approximately 80% ofCanadians live within 160 km of the Canada–United Statesborder [23] – and there is marked intra-provincial urban–rural variability [24]. Many systems of intra-provincialregionalization of care that are responsive to populationdensity, geographic barriers, or evolved regional caresystems also may lead to differences in the distribution ofcritical care services. Moreover, despite provincial admin-istration of most healthcare services, there is also somewell-established inter-provincial ICU care, with regional-ized trauma services, specialized care delivery for northernterritories among bordering provinces, and populations ofone province that are closest to a specialized healthcarecenter in a neighboring province. It is not clear, however,whether specialized services’ referral relationships workwell during times of healthcare crisis such a pandemicwhen regions may react to future uncertainty by trying toconserve resources for more local use.This study has important limitations. First, this surveywas carried out using existing national and provincialdatabases of hospitals, and it is possible that some acutecare hospitals may have been missed. However, we subse-quently employed snowball sampling and web and mapsearching techniques to identify all hospitals and ICUs inacity across provincesrs capableve ventilationHigh-frequencyoscillatory ventilatorsHospitals withICUs with iNOHospitals withICUs with ECMO7 3 26 7 20 0 01 3 040 25 1265 19 1110 3 310 3 218 8 321 7 40 1 0178 79 39each province, and then sought out a combination ofphysician, nurse, respiratory therapist, and hospital ad-ministrator leaders to derive current ICU beds and venti-lator capacity at each hospital. After compiling local data,each participant and provincial health authority was giventhe opportunity to critique the aggregate estimates to im-prove accuracy. Second, population denominator-basedcomparisons may not be the optimal mechanism fornormalization in all regions with varying population dens-ity, age demographic differences, geographic barriers, anddistinct systems of regionalized care for some tertiary andquaternary services such as trauma and transplantation.However, our results indicate relatively wide variability inICU capacity among provinces and therefore may providehelpful inter-provincial comparisons. Third, this studyfocused on a very narrow spectrum of services needed toprovide critical care – ICUs, beds, ventilators, and special-ized supports for respiratory failure. It was beyond thescope of this survey to evaluate personnel (dieticians,nurses, pharmacists, physicians, physiotherapists, respira-tory therapists, social workers) or other resources that areessential to the care of critically ill patients. Indeed, lack ofFigure 1 ICU beds capable of invasive mechanical ventilation per 100,000 Canadian population according to health region.Table 2 ICUs and ventilation capacity according to 2009 population across provincesRegion Hospitals with ICUs per100,000 population (%)ICU beds with ventilation capacityper 100,000 population (%)Invasive ventilators per100,000 population (%)Newfoundland 2.8 19.3 24.4Nova Scotia 1.5 15.0 20.3Prince Edward Island 1.4 12.8 15.6New Brunswick 1.2 13.8 15.1Quebec 1.1 11.3 15.3Ontario 0.6 8.6 16.1Saskatchewan 1.3 10.5 22.8Manitoba 1.0 9.0 14.7Alberta 0.4 7.9 10.1British Columbia 0.8 6.8 10.3Territories 2.7 5.5 13.7Canada 0.9 9.5 14.9Fowler et al. Critical Care  (2015) 19:133 Page 5 of 8according to census division, Figure S2 showing the relationshipFowler et al. Critical Care  (2015) 19:133 Page 6 of 8available critical care clinical staff is among the most com-mon reason for limitations in bed availability [25-27]. Fu-ture resource planning must address this key knowledgegap. Fourth, ICU resources are not static, and this surveyrepresents a period prevalence of approximately 3 monthsat the hospital level and approximately 1 year among allsites, in a period after the H1N1 pandemic where know-ledge of ICU capacity may have been greatest.Our results highlight the need to examine capacity bothin relation to local needs and in comparison with otherregions. It is important to note that the organization ofcritical care within Canada has not been static since con-ducting this survey. Alberta has reorganized critical careservices under one structure, with a standardized provin-cial bedside clinical information system/electronic medicalrecord [28]. Since the severe acute respiratory syndromeexperience, the Ministry of Health and Long-term Care inOntario has maintained a Critical Care Strategy to overseea similar cataloguing of critical care services includingtwice-daily clinical updates of every patient in ICUs into acentralized electronic database that facilitates critical careinter-facility transportation services, reporting on qualitymetrics and decision-making on surge capacity [29].British Columbia and Nova Scotia have recently formedCritical Care Working Groups within the Ministry ofHealth to coordinate data collection and reporting, im-provement of care processes, transportation of criticallyill patients, and improvement of staffing models in ICUs.In 2011 Quebec created a Groupe d’Experts en SoinsIntensifs working with the Ministry of Health to improvequality and accessibility of ICUs and a mandate to estab-lish provincial ICU capacity.One of the lessons learned from the severe acuterespiratory syndrome and influenza A (H1N1) pandemicsis that infectious outbreaks do not respect regional healthboundaries [30,31] and that individual regions may beclinically overwhelmed while others are unaffected. Ofrelevance to surge planning, we were able to quantify theexcess numbers of invasive mechanical ventilators relativeto ICU beds, highlighting capacity that may exist beyondexisting ICU beds. The ability to provide advanced oxy-genation with one of three modes of support was availablein a minority of hospitals. Furthermore, this expertise wasunevenly distributed across provinces, and was focused atuniversity-affiliated teaching hospitals. However, we wereunable to gauge experience with specialized ventilationalongside capacity. We did not determine capacity forother techniques such as prone ventilation, which may beless dependent upon specific technology, more dependentupon generation of a local experience base, and have agreater evidence base for efficacy than either early high-frequency ventilation or use of inhaled nitric oxide [32].This variable and uneven distribution of expertise ob-served in this study demands that we evolve a system inbetween number of ICU beds capable of ventilation and populationby health region, and Figure S3 showing the relationship betweennumber of ICU beds capable of ventilation and population bycensus division, and contains the mapping methodology technicalnotes and the Canadian Critical Care Trials Group Capacity Survey.Key messages We identified all ICU beds and mechanicalventilators for critically ill patients in Canada. There was substantial variability in inter-provincialcapacity. There was only moderate correlation betweenventilation capacity and population size. During times of increased demand, variability inICU resources may result in geographic differencesin the ability to care for critically ill patients. These results highlight the need to evolve inter-jurisdictional resource, and provide background datafor the development of appropriate critical carecapacity benchmarks.Additional fileAdditional file 1: Contains Figure S1A showing ICU beds capable ofinvasive mechanical ventilation per 100,000 Canadian populationpatients. These results may guide future decision-making,but must also be complemented by estimates of currentand future healthcare personnel supply and projections ofdemand for critical care from an aging population [34].Greater ongoing knowledge of regional critical careresources may help us respond to increases in demandfrom unpredictable events such as infectious outbreaks orregional medical emergencies. While some regional imbal-ances may persist, there should be deliberate planning formechanisms to deal with both unexpected and day-to-daysurge in demand. Mechanisms are needed to rapidly shareand deploy resources – both equipment and personnel –across provincial boundaries to deliver a more equitable,coordinated, and responsive system of healthcare forcritically ill Canadians.which excess capacity in one region may aid another, ei-ther through safe transportation of patients or short-termmovement of equipment or personnel to existing ortemporary facilities [33].ConclusionICU resources vary widely across Canadian provinces, andduring times of increased demand may result in geo-graphic differences in the ability to care for critically illAbbreviationIQR: interquartile range.Fowler et al. Critical Care  (2015) 19:133 Page 7 of 8Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsRAF, PJ, DJC, JCM, and AFT conceived of the study. RF and PJ participated inthe design of the study. RAF, SMB, NB, DJC, PD, DF, RF, NG, RG, PJ, AK, FL, BL,AH, CM, LR, SS, HTS, AFT, GW, RZ, NKA, JG, DCS, and JCM collected primarydata. RAF and PA performed the statistical analysis. All authors read andapproved the final manuscript.AcknowledgementsYukon collaborators: KD Braden, Nora Tremblay, Bendan Hanley, RowenaBeckett, and Karin Heynen.Northwest Territories collaborators: Ivan Russell, Kami Kandola, Kathie Pender,and Elaine Kelly.Nunavut collaborator: W. Alexander (Sandy) MacDonald.British Columbia collaborators: Tracey Miller, Lynn Tran, Lauren Tindall,Michelle Stuart, Kevin Carriere, Elizabeth Jolley, Gordon Krahn, Jim Fitzpatrick,Lynn Smiley, Coleen Hay, Ophelia Spencer, Darla Roberts, Christina Gordon,Barb Caldwell, Jo-Annne Rondeau, Karen L Watson, Morag Mochan, JoanneCozac, Cheryl Scovill, Kathey Yeulet, Suzanne Johnston, Ray Taylor, PatTresierra, Rob Fingland, Christopher Gagnon, Monique Roy-Michaeli, GrzegorzMartinka, David Wensley, Peter Skippen, Sneeta Takhar, and Don Griesdale.Alberta collaborators: Monique Roy-Michaeli, Ari Joffe, Elaine Gilfoyle,P Wickson, Catherine Ross, Chip Doig, Paul Boiteau, and David Zygun.Saskatchewan collaborators: Susan Lyons, Anita Sagadahi, Laurie Albinet,Gayle Riendeau, Pam McKay, Ndrew McLetchie, Barbara Jiricka, CarolGregoryk, Val Davies, Valerie Mann, Saqib Shahab, Patrick O’Byrne, DianeLarrivee, Sandy Bradford-Macalanda, and Alice Wong.Manitoba collaborators: Kimberly Webster, Scott Cleghorn, Gregg Eschun,Allan Garland, Charlie Penner, Murray Kesselman, and Gordon Kasian.Ontario collaborators: Carol Moran, Jeff Singh, Judith Van Huyse, SonnyDhanani, Jamie Hutchison, John Muscedere, Stephen Lapinsky, KusumMenon, Karen Choong, Tom Stewart, Margaret Herridge, Douglas Fraser,Karen Burns, and Niall Ferguson.Quebec collaborators: Baqir Quizibash, Jean Philippe Garant, LysanneDesaindes, Vanessa Dutil, Craig Baldry, Francois Lellouche, Pjil Roula, AshGursahaney, Arnold Kristoff, J-S Bilodeau, Mathieu Bernier, Jean-Luc Houde,Marisa Tucci, Marc-Andre Dugas, Dina Diana, Miriam Santschi, Denny Laporta,Dominique Piquette, Davinia Withington, Germain Poirier, Martin Legare,Jacques Lacroix, Stephane P. Ahern, Dr. François Lauzier, and Tina Doyle.New Brunswick collaborators: Carolin Galvin, Rachel Mallais, Marchel Mallet,Kathy Kowalski, Claude Violette, Stephanie Perry, Colleen Reinsborough,John Mowat, Todd Lambert, Krista Chillington, Judy Melanson, JoanneMichaud-Young, Marc Pelletier, Krista Shillington, and Jean Bustard.Prince Edward Island collaborators: Judy Adams, Sherry Harris, and Kay Kelly.Nova Scotia collaborators: Anne McClair, Linda Rouleau, Dietrich Henzler,Rebecca Earle, Nadine Stevens, Maria Marshall, Jill Smith, Wendy Studley,Norah Doucet, Angela Foote, Dorothy McCaskil, Sharon McCarthy, KimThomasl Kate Mahon, Shauna Best, Chris Soder, and Rick Hall.Newfoundland and Labrador collaborators: Jill Barter, Gerry McCain, KimAduau, Sharon Penny, and Valery Clarke.Public Health Agency of Canada collaborators: Rachel Rodin, Corey Oliver,Ahalya Mahendra, Joy Pulickal, Marianna Ofner, and Kara Hayne.FundingThis study was supported by the Public Health Agency of Canada, CanadianInstitutes of Health Research. The Public Health Agency of Canada assisted incollection and analysis of the data. The funders had no role in theinterpretation of data, in the writing of the manuscript, and in the decisionto submit the manuscript for publication.Author details1Interdepartmental Division of Critical Care Medicine and Department ofMedicine, University of Toronto, Toronto, Canada. 2Department of CriticalCare Medicine, Sunnybrook Hospital, 2075 Bayview Avenue, Room D138,Toronto, Ontario M4N 3M5, Canada. 3Office of Situational Awareness andOperations, Centre for Emergency Preparedness & Response, Health SecurityInfrastructure Branch, Public Health Agency of Canada, 100 Colonnade Road,Ottawa, Ontario K1A 0K9, Canada. 4Adult Intensive Care, Island HealthAuthority, Royal Jubilee Hospital, 1952 Bay St, Victoria, BC V8R 1J8, Canada.5Critical Care Research, Vancouver General Hospital, JPPN, ICU, Room 2469899 12th Avenue West, Vancouver, BC V5Z 1M9, Canada. 6Division of CriticalCare Medicine, 3C1.16 University of Alberta Hospital, 8440-112 Street,Edmonton, AB T6G 2B7, Canada. 7Memorial University of Newfoundland,Discipline of Medicine, Memorial University of Newfoundland, St John’s, NLA1B 3V6, Canada. 8Department of Anesthesia and Critical Care Medicine, andPopulation Health and Optimal Health Practices Research Unit, CentreHospitalier Universitaire (CHU) de Québec and Université Laval, 1401, 18eRue, H-037, Québec G1J 1Z4, Canada. 9Centre Hospitalier Universitaire deSherbrooke Service de médecine interne (local 4223), 3001 12e Av. N.,Sherbrooke, Québec J1H 5N4, Canada. 10Section of Critical Care Medicineand Section of Infectious Diseases, Departments of Medicine and MedicalMicrobiology, University of Manitoba, 710 Park Blvd, South Winnipeg, MBR3P-0X1, Canada. 11University of Manitoba, ON2051 – 675 McDermot Ave,Winnipeg, Manitoba R3E 0V9, Canada. 12Dalhousie University MedicalDirector, Trauma Nova Scotia, Halifax, Canada. 13Division of Critical CareMedicine, Department of Emergency Medicine, Room 349 Bethune Bld, 1276South Park St, Halifax, NS B3H 2Y9, Canada. 14Division of Critical CareMedicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124EClinical Sciences Building, 8440-112 ST NW, Edmonton T6G2B7, Canada.15Department of Critical Care Medicine, Institute for Public Health, Universityof Calgary and Alberta Health Services, 3280 Hospital Drive NW, Calgary, ABT2N 4Z6, Canada. 16IH Critical Care Network Medical Director, Critical Care,Kelowna General Hospital, 2268 Pandosy St, Kelowna, BC V1Y 1T2, Canada.17Critical Care Medicine, University of British Columbia. Vancouver CostalHealth Research Institute, Research Scientist, Center for Health Evaluation andOutcome Sciences, 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.18University of Saskatchewan College of Medicine’s Department ofAnesthesiology, Perioperative Medicine and Pain Management, RoyalUniversity Hospital, 103 Hospital Drive, Saskatoon, Saskatchewan S7N 0W8,Canada. 19Medicine, Faculty of Medicine, University of Toronto. Head,Division of Respirology University Health Network, Mount Sinai Hospital,Women’s College Hospital, University Health Network, 11-124 PMB, TorontoGeneral Hospital, 585 University Ave, Toronto, Ontario M5G 2N2, Canada.20Department of Surgery, University of Toronto. Provincial Lead, Critical Careand Trauma, Critical Care Services Ontario, St. Michael’s Hospital 30 BondStreet, Toronto, ON M5B 1W8, Canada. 21Lawrence S. Bloomberg Faculty ofNursing, University of Toronto, Sunnybrook Hospital, 2075 Bayview Avenue,Room D138, Toronto, Ontario M4N 3M5, Canada. 22St. Joseph’s Hospital,McMaster University, Hamilton, Ontario L8N 3Z5 , Canada. 23Keena ResearchCenter of the Li ka Shing Knowledge Institute of St. Michael’s Hospital, 30Bond Street, Toronto, ON M5B 1W8, Canada. 24Critical Care Western andLondon Hospitals. Professor, Schulich School of Medicine & Dentistry,Western University Scientist, Centre for Critical Illness Research, LawsonHealth Research Institute, Room D2-528 London Health Sciences Centre –Victoria Hospital PO Box 5010 800 Commissioners Road, East London, ONN6A 5W9, Canada. 25Director of the Pediatric Intensive Care Unit/chef deservice des soins intensifs pédiatriques, CHU Sainte-Justine, 3175 Cheminde Côte Sainte Catherine, Montreal, Québec H3T 1C5, Canada.Received: 1 July 2014 Accepted: 3 March 2015References1. Shahpori R, Gibney N, Guebert N, Hatcher C, Zygun D. 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