Tory Trauma Research

The Department of Critical Care Medicine has a clinical research program whose overarching objective is to improve the understanding of critical illness and deliver the best possible patient care. Our clinician-scientists have expertise in a range of health services methodologies, including observational studies (using clinical data and large administrative datasets), surveys, meta-analyses, qualitative evaluations and randomized controlled trials. Our team includes clinician-scientists, a biostatistician, a research manager and two research coordinators.

We participate in a broad range of research, including projects initiated within our department and those led by other academic investigators and the health care industry. Our researchers are supported by and have received peer-reviewed grants from many sources, including the Canadian Institutes of Health Research and U.S. National Institutes of Health.

Projects include those in the following areas:

• Neurocritical care
• Trauma, including in geriatric patients
• Perioperative care of patients undergoing cardiac surgery
• Sepsis
• Acute kidney injury
• Prehospital interventions to prevent or mitigate the effects of critical illness
• Prevention of complications acquired in the intensive care unit (ICU)
• Quality improvement in the delivery of care in the ICU
• Medical and interprofessional education and practice
• Communication with patients and their families
• End-of-life care
• National and international comparisons of care
• Organization of trauma and critical care services within health systems
• Critical illness and care delivery in resource-constrained settings

For details, see individual faculty pages.

The department of emergency services at Sunnybrook Research Institute (SRI) is made up of several interdisciplinary teams committed to advancing patient care and improving individual and public health. Their areas of focus include the following:

• clinical and health services research focused on prehospital care;
• the emergency care of older people;
• prevention of delirium; and
• implementation science.

Current projects include the Paramedics assessing Elders at Risk for Independence Loss (PERIL) study and the Enabling Teamwork, Interprofessional Collaboration and Education (EnTICE) project. The PERIL study is an observational study on paramedics assessing elderly people at risk for independence loss, with an aim of identifying seniors at high risk for harmful outcomes after an encounter with emergency medical services (EMS). The EnTICE project aims to create a best-practices, evidence-based toolkit that will be useful for frontline critical care and emergency department teams, and help improve specific patient outcomes.

Care for acutely ill patients begins while they are in an ambulance or a helicopter—long before they reach the hospital. Research begins there, too.

The Prehospital and Transport Medicine Research Program is the largest of its kind in Canada. It has a relationship with prehospital providers from six regions in southern Ontario, and is affiliated with 43 Canadian academic and community hospitals. Research spans several areas.

Through strong collaborations with regional emergency medical services and the Sunnybrook Centre for Prehospital Medicine, researchers at SRI are working to determine the best strategy for classifying heart attack patients diagnosed by paramedics according to the urgency of their need for care. They will be comparing a strategy of using a clot-busting medication immediately given by paramedics in the home, versus a strategy of rapid transport directly to a specialized cardiac centre for a procedure to physically open the blocked artery with a catheter.

Early, high-quality chest compressions (cardiopulmonary resuscitation or CPR) performed by bystanders increase the chances of survival after sudden cardiac arrest. SRI researchers are studying barriers to laypeople performing CPR in the prehospital setting and exploring solutions to these barriers. They are focusing on ways to improve CPR instructions given over the phone by 911 operators while emergency medical services are dispatched.

Researchers in emergency medicine, in collaboration with the Institute for Clinical Evaluative Sciences, which is located on the Sunnybrook campus, are also working to identify the explanations for delays in emergency care, techniques to reduce wait times and tools to deploy emergency resources more efficiently.

Other research projects include the following:

• identifying the best electrical waveforms for defibrillating cardiac arrest patients; and
• developing tools to know when to stop resuscitation.

For more information, visit the department of emergency services or the Centre for Prehospital Medicine web site.

Advances in burn care developed by Sunnybrook’s experts over the last two decades have helped improve patients’ burn assessment treatments in Ontario. The Ross Tilley Burn Centre is a state-of-the-art facility providing tertiary care for the majority of burn injury patients in the province.

The centre offers training in burn care and burn research to medical students, postgraduate surgical and critical care residents, and surgical and critical care fellows. It has on-site facilities for health research activities on burn research.

Read more about the Ross Tilley Burn Centre.

Trauma scientists at Sunnybrook Research Institute (SRI) are leading a multicentre study to explore the immunological and anti-inflammatory effects of hypertonic saline as part of the North-American-wide Resuscitation Outcomes Consortium. Sunnybrook is one of only three institutions funded by the National Institutes for Health, Canadian Institutes of Health Research and Defense Research Development of Canada to evaluate whether concentrated salt solutions provided early to injured patients can prevent delayed organ failure that leads to death.

Trauma researchers at SRI are also developing and testing novel diagnostic tools to detect and treat traumatic coagulopathy. They are using old technology in new ways to monitor blood clotting to understand why some patients still bleed to death after trauma. With funding from Defense Research Development of Canada, they are working to identify techniques that will prevent these unnecessary deaths.

Other areas of investigation include:

• the role of alcohol in the outcome of patients with head injury;
• radiation exposure in trauma;
• causes of mortality in trauma; and
• the delay in time for surgery in trauma as a marker of quality of care.

To understand if treatments such as drugs or procedures affect outcomes like symptoms, quality of life and survival, medical researchers conduct studies comparing outcomes of patients that receive a treatment, to outcomes of patients that do not. However, because many treatments are complex in that they involve multiple parts or people, it can be difficult to understand the meaning of study results because of local differences influencing the way the treatment being studied was introduced and delivered.

A process evaluation is a study that occurs alongside a main study. It enables understanding of factors that influence how a treatment was introduced and maintained during a study, and how much of the treatment was delivered as planned. We will conduct a process evaluation of a multicentre study looking at whether antibiotics given to critically ill adults during admission to an intensive care unit (ICU) to prevent rather than treat an infection reduces death, antibiotic use and antibiotic resistance rates. The study is the Selective Decontamination of the Digestive tract in Intensive Care Unit patients study.

We will conduct surveys, interviews and audits, and observe practice in ICUs taking part in the trial to understand:

• how the treatment was introduced at each ICU and maintained over time
• if the treatment was delivered as planned
• what this information can tell us to understand the results of the main trial.

Our process evaluation will enable us to understand better if preventive antibiotics save lives and reduce antibiotic usage, and their impact on antibiotic resistance. It also will give us information about whether we could expect the same findings if we introduced the intervention into other ICUs after the study and how best to do this.

Antibiotic resistance, driven by the overuse of antibiotics, is a huge threat to public health in Canada. At the same time, infections are a major cause of death and increase health care costs. Critically ill patients are particularly susceptible to infections caused by antibiotic-resistant organisms and have an even higher rate of death.

Significant tension exists between avoiding inappropriate antibiotic use and preventing life-threatening infections. One intervention used to prevent infections and reduce deaths is selective decontamination of the digestive tract (SDD), a preventive antibiotic regimen. Health care professionals have refrained from using SDD owing to fears that increased use of antibiotics will drive antibiotic resistance. Whether these fears are justified is unknown. Currently, we deny patients a potentially lifesaving preventive therapy out of concern for the risk of antibiotic resistance. Therefore, further study is imperative to determine the balance of benefit and harm of this regimen.

We are funded by the Canadian Institutes of Health Research’s Strategy for Patient-Oriented Research (SPOR) to study whether SDD saves the lives of patients to whom it is delivered. Yet, this question is only one of the two key questions we need to answer before this treatment is implemented. We also need to know whether this regimen drives antibiotic resistance, thus potentially putting other patients’ lives at risk due to difficult-to-treat infections caused by antibiotic-resistant organisms. The microbiome is the key to understanding how and why antibiotics could drive antibiotic resistance.

We are commencing the SPOR-funded randomized controlled trial. Alongside this trial, we propose to perform a study of the impact of antibiotic usage on antibiotic resistance patterns in ICUs by studying the microbiome. If this treatment can save lives without causing antibiotic resistance, then this study could have global impact through lives saved and infections prevented, and by reducing health care costs.

Antibiotic resistance, driven by the overuse of antibiotics, is a huge threat to public health in Canada. At the same time, infections are a major cause of death and drive health care costs. Critically ill patients are particularly susceptible to infections caused by antibiotic-resistant organisms and have an even higher rate of death. Significant tension exists between avoiding inappropriate antibiotic use and preventing life-threatening infections.

One intervention used to prevent infections and reduce deaths is selective decontamination of the digestive tract (SDD), a preventive antibiotic regimen. Health care professionals have refrained from using SDD owing to fears that increased use of antibiotics will drive antibiotic resistance.

We are funded by the Canadian Institutes of Health Research’s Strategy for Patient-Oriented Research to study whether SDD saves the lives of patients to whom it is delivered. Yet, answering this question alone will not tell us whether this treatment represents good value for money in intensive care units around the world. Modern health care systems simply cannot afford to implement new treatments without knowing the answer to these important questions. To determine whether SDD represents good value for money for the health care system, we will perform analyses that weigh the benefits and costs of SDD.

Principal investigators

• Dr. Brian Cuthbertson, Canadian and international principal investigator
• Dr. Louise Rose, Canadian co-principal investigator
• Dr. Srinivas Murthy, Canadian co-principal investigator
• Dr. John Myburgh, Australian principal investigator
• Dr. Anthony Gordon, U.K. principal investigator

Manager

• Ms. Mariam Saleem, Canadian project manager

The George Institute for Global Health SuDDICU website

SuDDICU Twitter feed

SuDDICU on ClinicalTrials.gov

1. Cuthbertson BH, Campbell MK, MacLennan G, Duncan EM, Marshall AP, Wells EC, Prior ME, Todd L, Rose L, Seppelt IM, Bellingan G, Francis JJ. Clinical stakeholders’ opinions on the use of selective decontamination of the digestive tract in critically ill patients in intensive care units: an international Delphi study. Crit Care. 2013 Nov 8;17(6):R266. doi: 10.1186/cc13096.
2. Daneman N, Sarwar S, Fowler RA, Cuthbertson BH; SuDDICU Canadian Study Group. Effect of selective decontamination on antimicrobial resistance in intensive care units: a systematic review and meta-analysis. Lancet Infect Dis. 2013 Apr;13(4):328–41. doi: 10.1016/S1473-3099(12)70322-5.
3. Cuthbertson BH, Francis J, Campbell MK, MacIntyre L, Seppelt I, Grimshaw J; SuDDICU study groups. A study of the perceived risks, benefits and barriers to the use of SDD in adult critical care units (the SuDDICU study). Trials. 2010 Dec 3;11:117. doi: 10.1186/1745-6215-11-117.

• Opioid prescribing before and after critical illness (CIHR funded)
• Opioid prescribing after surgery (NIH funded, in collaboration with University of Pennsylvania)
• Sedative prescribing after critical illness (CIHR funded)
• Rehospitalizations after critical illness (CIHR funded)
• End-of-life care in Canada (TVN grant)
• Care and outcomes for hematologic malignancy patients with critical illness
• Care of elderly trauma patients
• Triage practices for trauma patients
• Trends over time in health care utilization