Hello and welcome to today's Journal Club Critical Care Medicine webcast. The webcast hosted and supported by the Society of Critical Care Medicine as part of the Journal Club Critical Care Medicine series. This webcast features two articles that appear in the August 2022 issue of Critical Care Medicine. This webcast is being recorded. The recordings will be available to the registrants on demand within five business days. All you need to do is simply log into mysccm.org and navigate to the My Learning tab. My name is Tony Gerlach and I'm a Clinical Critical Care Pharmacist at The Ohio State University Wexner Medical Center here in Columbus, Ohio, and I will serve as today's moderator. Thank you for joining us and just a few housekeeping items before we get started. There will be a question and answer or Q&A session at the conclusion of both presentations. To submit your questions anytime throughout the presentation, simply type them into the question box located in your control panel. If you have a comment to share during the presentation, you may use the question box for that as well. And finally, everyone joining us for today's webcast will receive a follow-up email that will include evaluation. Please take five minutes or so to complete the evaluation as your feedback is greatly appreciated. And please note the disclaimer stating that the content to follow is for educational purposes only. And now I would like to introduce today's speakers. Our first speaker is Dr. Svetlana Hersevich. She's a Research Fellow and an Assistant Professor of Anesthesiology in the Department of Anesthesiology and Perioperative Medicine at the Mayo Clinic in Rochester, Minnesota. She's a member of METRIC, which stands for Multidisciplinary Epidemiology and Translational Research in the Intensive Care Research Group, which is focused on systematic research and quality improvement initiatives to reduce complications, improve outcomes of critically ill patients. Her current research focuses on evaluation of digital health strategies that reliably stratify patients according to their need and priority attention and intervention from critical care clinicians, something I think we're going to hear more and more of in the future. And our second presenter is Dr. Carla Krulok, who's a Senior Research Associate in the Department of Critical Care Medicine at the University of Calgary. She received her Ph.D. in Biochemistry from the University of Calgary. In her current role, she coordinates Dr. Kristen Feist's research program. Her research interests include engaging families of critically ill patients in delirium prevention, detection, and management. Thank you both for joining, and now I'm going to turn the presentation over to Svetlana. Hello, Dr. Krulok. Hello, everybody. Thank you for having me here. And today, I would like to present the results of my recently published systematic review on the impact of health information technology for early detection of patient deterioration on mortality and length of stay in the acute care settings. I personally have nothing to disclose. One of my co-authors, Dr. Pickering, is a board member of Ambient Clinical Analytics, and the remaining authors don't have any potential conflicts of interest. I would like to start my presentation with one major problem of the contemporary hospital and ICU in particular, and one definition. So the big problem I would like to raise today is an information overload. We all know that a comprehensive electronic medical record provides all patient-related information which is captured during the everyday care, during the decision-making in the hospital, and the quantity of information is enormous. Especially information generated to the ICU patients can be 10 times more than in other hospital settings. Definitely, we observe the information burden, which has three negative consequences. It impacts, first of all, significantly clinician cognitive reasoning, timeliness of medical decision-making, and can contribute to medical errors. We know from the previous research that worsening in a patient clinical condition may remain undetected for hours prior to escalation of care. At the same time, early identification of patients at high risk of deterioration enables ICU clinicians to alter the trajectory of the disease before it leads to irreversible harm. And the third negative consequence of information overload is that it increases the possibility of diagnostic errors and delay. Diagnostic errors, as you can see in this slide, have multiple causes and several potential solutions. And you can see that some of these solutions are integrated into one concept, and this concept is a health problem. And this health problem, as you can see, is a health information technology. And it's time for the definition. So health information technology, HIT, incorporates various information sources, data, and technology to facilitate improved communication and clinical decision-making in hospitals. It includes such intervention as EMR itself, computerized physician order entry, clinical decision support systems, novel user interface designed to support decision-making, and surveillance systems or sniffers. Several systematic reviews were done to assess the impact of health information technology on patient outcomes. And they have one big common thing. There was no effect on mortality. This meta-analysis published in 2015 included a broad variety of health information technology interventions and didn't show the effect on mortality. Another meta-analysis. Authors reported process improvement assessed with the health information technology. And again, no effect on mortality has been demonstrated. One more study. This was a systematic review focused on computerized decision support systems. And they didn't do the meta-analysis and didn't provide any convincing evidence of improvement of hospital mortality. And as our research group is focused on the problem of timeliness of interventions and preventing of diagnostic errors, the objective of my systematic review was to evaluate the impact of the special subset of health information technology. HIT specially designed to early detection of patient deterioration implemented into practice on mortality and length of stay in the acute care hospital setting. Eligible studies included the following. They enrolled adult patients hospitalized on floor, ICU, or evaluated in the emergency department. They assessed health information technology for early detection of patients, deteriorating patients, or at high risk of deterioration as an intervention compared to usual care in the study setting, and evaluated at least one endpoint of interest, hospital length of stay, ICU length of stay, or mortality at any time point. We excluded studies that used health information technology intervention not for detecting deterioration like CPOE, EMR itself, or developed and validated but not implemented into clinical practice. We searched studies from 1990 to January 2021. And we performed meta-analysis when at least three eligible studies included the desired outcome. Meta-analysis were performed separately for randomized controlled trials and for proposed studies. And we evaluated heterogeneity between studies using the I-squared statistics and conducted predetermined subgroup analysis based on the study setting, emergency department, hospital floor, or ICU, type of patient deterioration identified by health information technology we divided into sepsis, AKI, and other, and risk of bias to explore the potential sources of heterogeneity. Of more than 2800 of papers identified by our literature search, 30 were included to the systematic review, and 21 of them were included in the meta-analysis. The final cohort, the final set of studies included seven randomized controlled trials and 23 proposed studies. And some studies assessed outcomes of interest among the entire study cohort, and other studies only assessed the outcomes among those patients who met criteria for deterioration, both in intervention and in comparison group. So we conducted two types of meta-analysis, one evaluating the mortality and hospital length of stay for all included study patients for the entire study cohort, and one evaluating only those patients who reached the alert threshold defined for each study and therefore detectable by health information technology intervention. On this slide, you can see the meta-analysis on the impact of HIT intervention on hospital mortality. We found similar results in both groups. Studies provided the numbers for the entire study cohorts, and studies assessed the outcomes only in those patients who met criteria for deterioration. And hospital mortality was the highest among the entire study cohort. And hospital mortality didn't differ in patients receiving HIT intervention versus usual care in the randomized controlled trials. At the same time, meta-analysis of the proposed studies demonstrated significant association between health information technology and decrease in hospital mortality. Similar results were received in the meta-analysis of the effect of health information technology on the hospital length of stay. So HIT implementation was associated with significant reduction of length of stay in the proposed studies, but no difference was observed in the randomized controlled trials. If you look deeper in the published paper, you can find much more details and lots of supplemental materials, including subgroup analysis, sensitivity analysis, and even cumulative analysis. And analyzing all that, we didn't find any strong evidence that health information technology effectively decreases mortality in length of stay in any particular setting or for any specific type of deterioration. So we can conclude that there is a contradiction between the findings in randomized controlled trials and proposed studies. The implementation of health information technology for early detection of deterioration in acute care settings was not significantly associated with improved mortality or length of stay in the meta-analysis of randomized controlled trials and was associated with significant improvement in the proposed studies. And the main question is why? We believe that this difference may be secondary to multiple potential confounders, including practice advances and quality improvement initiatives rather than health information technology implementation itself. We analyzed the potential contributors to improved outcomes in these proposed studies and found out that it's very important how health information technology was implemented. Which training, education of staff was performed, was health information technology a part of broader quality improvement project or complex multi-component intervention or not? And changes in clinical practice over time and short-term effect when participants perform better when they know that they are in the intervention group may also affect the result and make it more positive in the proposed studies. And in our study we found that there is still a gap between expectations and real positive effects of new IT technologies in the acute care settings. From the previous research I can add that similarly artificial intelligence solutions largely fail to identify accurately, accurately and timely those patients with evolving of critical illness. And at the end of my presentation I would like to add that in my opinion further development and implementation of new digital health technologies must be based on the deep understanding of need of clinicians working with acutely ill patients. I mean understanding of their information needs and processes facilitating patient prioritization in hospital and especially in the ICU. And I also want to emphasize that it's important to develop and extend safety culture in the acute care settings and to focus not only on the ultimate patient outcomes but on such important patient-centered outcomes as quality of life, quality of time and quality of clinical relationship, relationship between patient and family, physician and patient and family. And another focus should be on the interventions that minimize clinician cognitive load, potentially can minimize clinician burden, and health information technology may be very helpful in this content. Thank you the audience for the attention and now I would like to turn it over to Carla to present. Thanks. Thank you Svetlana and thank you to the Society of Critical Care Medicine for the opportunity to speak about our team's work. So again my name is Carla and I'm a part of a Canadian team who is working with Sepsis Canada to improve public knowledge of sepsis and the sepsis journey in Canada by engaging, educating and empowering individuals really to be informed stewards of their own health care. So for today's webcast I will be focusing on our recent scoping review titled patient public and health care professional sepsis awareness knowledge and information seeking behavior. So I have no conflicts of interest to declare on my behalf or on behalf of the team but I just want to note that the work that I'm about to present was supported in part by a peer-reviewed funding proposal awarded to doctors Kirsten Feist and Gina Parsons-Lee through Sepsis Canada. And I also want to mention that Sepsis Canada is a multidisciplinary network funded by the Canadian Institutes of Health Research. However the Canadian Institutes of Health Research had no role in the design, conduct, analysis or publication of this research. And I also want to mention that I am presenting on behalf of a broader team today and our broader team includes patient partners, research and clinicians from across Canada. Listed here are the researchers, study team members and intensivists who are part of this scoping review team which includes a group from the University of Calgary that I'm a part of, Dalhousie University and also some individuals from Sepsis Canada. So I'd like to begin by touching on why raising sepsis awareness is so important. As most of us on the webcast are likely aware sepsis is a life-threatening response to an infection. Almost any infection bacterial, viral or fungal including COVID-19 can lead to sepsis and sepsis is a medical emergency. So knowing the risks and being able to spot the symptoms and seek medical help could save a life. In 2017 there were 48.9 million sepsis cases reported and 11 million sepsis related deaths worldwide. So one in five people diagnosed with sepsis died. Moreover sepsis is reported to be responsible for the most deaths worldwide even more than cancer or coronary disease. However I should note that incidence rates vary by country and challenges with clinical identification of sepsis persist. Sepsis also accounts for billions in health care costs and costs due to long-term outcomes of neurocognitive, psychological, physical and mental medical complications related to sepsis. So it is crucial to recognize early signs and symptoms of sepsis to enable rapid treatment that improves survival rates and long-term adverse outcomes. And lastly most sepsis cases start in the community and those sepsis may be preventable in some cases. It is not widely recognized by patients and general public and knowledge gaps persist among health care professionals. So increasing public and health care professionals awareness of sepsis, its risk factors and its symptoms are crucial to reducing the global burden of sepsis. Before going into details of the scoping review I think it's really important for us to pause and take a moment to note some of the campaigns, bundles and organizations who had a major impact on sepsis awareness and treatment over the last 20 years. This includes consensus definitions of sepsis. This is presented as sepsis one, two and three on the timeline that on your screen. And this began in 1991 when a consensus conference or sorry 1992 when a consensus conference developed initial definitions of sepsis and this has been updated since. Another important event is the inception of the surviving sepsis campaign at the annual meeting of the European Society on Intensive Care Medicine in Barcelona in 2002. The first initiative of the surviving sepsis campaign that was coined the Barcelona Declaration aimed to reduce sepsis mortality by 25% within five years through urging health care professionals and governments to improve sepsis management through an action plan. And this action plan identified six challenges associated with sepsis. One of those is awareness and the other is diagnosis, treatment, education, counseling and referral. And also there are several key organizations that this is by no means an exhaustive list such as Global Sepsis Alliance, UK Sepsis Trust and these have been created in response for the need to increase sepsis awareness. There's World Sepsis Day which occurs every September 13th again aimed to increase sepsis awareness. And lastly more recently in 2017 the WHO called on the global community to improve the prevention, diagnosis and treatment of sepsis. And this is actually when Sepsis Canada was created in response to this WHO's resolution. So in preparing to develop our own national survey in Canada we decided to look at what has been reported in the peer-reviewed literature to investigate awareness and understanding of sepsis. So to this end we conducted a scoping review and just briefly a scoping review. It's a method of knowledge synthesis and it aims to map the literature on a particular topic or research area to identify key concepts, gaps in the research and types and sources of evidence. So the stated aim of our scoping review was to identify and map the literature related to sepsis awareness, general knowledge and information seeking behaviors with a goal to inform future sepsis research and knowledge translation campaigns. So before we embarked on the scoping review we enlisted the help of a librarian to co-develop a search strategy. On May 3rd 2021 we searched for research databases which are in the green rectangles at the top of the screen for MeSH terms and keywords related to sepsis awareness, knowledge and information seeking behaviors and in conjunction with terms and keywords related to sepsis. We placed no language or date restrictions on our search. We excluded published commentaries, editorials, reviews, conference abstracts, proceedings and articles that focused on clinical knowledge of sepsis. So our search captured just under 6,000 unique studies. After screening titles and abstracts of these articles we reduced the number to 608 and after screening the full text we identified 80 articles that met our inclusion criteria for data abstraction. So of the 80 included studies 16% reported on patients, 19% on public and 60% on health care professionals. The colors that are used in the slide are important. The data that will be presented later if it's orange it's related to public or sorry patients. If it's green it's related to the public and if it's in blue it's related to health care professionals. Also important to note is patients included sepsis survivors, postnatal mothers, people with learning disabilities, pre-operative patients and surrogates of sepsis patients. And healthcare professionals included pre-hospitals such as emergency medical technicians or dentists and in-hospitals such as nurses and physicians. Now, when we looked at the 80 articles, we quickly identified that the literature seemed to report on eight domains of sepsis knowledge. So this included awareness, signs and symptoms, mortality, information seeking and information sources, definitions, risk factors and education. So during the remainder of this webcast, I will present on a selection of these domains of sepsis knowledge. So the first domain is awareness. So this graph represents patient, public and healthcare professional awareness of sepsis over time. And in relation to those international consensus based sepsis definitions that are shown with the vertical dotted lines. The points on the graph represent the proportion of participants in each study that reported being aware of sepsis. And awareness was most commonly measured by the question, have you heard the term sepsis? Now the green dots, the green circles represent the studies focused on public, the orange squares represent patient focused studies and the blue triangles represent studies with healthcare professionals. As you can see public awareness of sepsis varied globally, though trends to gradual improvement over time, particularly with the inception of organizations and large scale awareness campaigns that promoted sepsis awareness. And again, those that are depicted with the vertical dotted lines. It's also clear from the graph and this was not a surprise with this scoping review is that the proportions of healthcare professionals, a higher proportion of healthcare professionals were aware of sepsis when compared to public and patients. Yet there's still variability across studies. And particularly we found this variability between pre-hospital personnel like EMTs and in-hospital personnel. 30 of the 80 studies reported on knowledge of the definition of sepsis. Similarly, proportions of the public shown in green who are able to correctly identify a definition of sepsis range from 4% in Singapore to 92% in Sweden. And just to orient you to the graph here, the bars in the graph represent ranges and proportions where multiple studies conducted in the same continent reported proportions. And the X is a single study in that continent. Again, healthcare professionals knowledge of sepsis definitions were generally higher than members of the public, but it's still varied considerably across studies. And this is another slide related to definitions. Prior to the conduct of this scoping review, we know the inconsistency in sepsis definitions has plagued the field, which was further exacerbated by changing definitions while other influential bodies continue to use old definitions. So to demonstrate this complexity, there's two circles. The blue circle includes those definitions that were identified as correct in studies that surveyed healthcare professionals. And the green circle includes sepsis definitions that were identified as correct in studies that surveyed members of the public. And the overlapping parts of the circle include definitions that were found in both healthcare professional and public center studies. It should be noted that sepsis definitions from included studies show important, yet slight variation in interpretation and description. And most of these definitions are different, but some have overlapping elements. So for example, I showed some words in orange of definitions in healthcare professional studies that included organ dysfunction and infection. So really I think this kind of underpins or I guess emphasizes the importance of a uniform global definition of sepsis. And also this global definition should incorporate plain language definition too for public's patients and families. A total of 33 studies evaluated patients, public or healthcare professional knowledge of the signs or symptoms of sepsis. It should be noted that 27 of these 33 studies evaluated healthcare professionals knowledge of the symptoms. Two studies were conducted before the release of the third international consensus definition, sepsis 3. And so it included leukocytosis or leukopenia and decreased blood sugar. And only knowledge of fever as a sign of symptoms of sepsis was evaluated in patient-focused studies wherein all core signs and symptoms except hypothermia were evaluated for public-focused studies. So the range is in the proportions of patients, public or healthcare professionals who correctly identified. And when I say correctly, I mean per each study's definition. So public or healthcare professionals who correctly identified any signs and symptoms of sepsis are displayed. And also I thought it was important to display to the right of the screen as well that there's a chart that displays the corollary words used in public studies for the more technical words indicating the signs and symptoms. Though one may argue the lay terms for altered level of consciousness maybe could improve. Sepsis Alliance uses in their It's About Time campaign uses the phrase mental decline, which may be a little more accessible to the lay public. And lastly, the last I mentioned is information. Most patients reported getting their information from hospital or medical personnel and also newspapers. Most healthcare professionals received their sepsis information from their profession or from school. And most public reported they got their information from media or the internet or from school. Now I wanted to include some interesting findings. So when evaluating the search volume or sepsis-related searches, the top search terms included are the ones on that computer screen. They included sepsis meaning, sepsis guidelines, what is sepsis, sepsis disease, and sepsis ICD-10. And most patients reported using Wikipedia, health websites, medical dictionaries, or discussion forums. And the main reasons they searched for health information was to learn about sepsis or treatments or what questions they should ask their physicians because they've never heard of it before. The last little green graph there, it just shows that the relative search volume of sepsis increased over time. And this increase was associated with awareness events and news media coverage. So high-profile deaths, healthcare system failures, and less commonly with awareness campaigns, World Sepsis Day. Although I wanna mention that one study did find a relative increase in digital information seeking associated with the sepsis of World Sepsis Day when compared to prior to World Sepsis Day. So before I go over the key findings from the study, I wanna mention a few important study limitations. It should be noted that we use general MeSH terms and keyword for sepsis. So it's possible that the healthcare professional general sepsis knowledge papers were missed. So any interpretations of sepsis awareness in these populations really requires further study. Most of the questionnaires used to evaluate patient, public, or healthcare professional knowledge were multiple choice. And this means that someone could have picked the correct answer just by chance. So maybe the estimates of correct might be higher due to that chance. Not all studies use the same measure or apply the same question or response options as such. It is difficult to draw global comparisons, though it should be noted that most public focus surveys use similar questions. And last included studies were cross-sectional, so included a snapshot of knowledge and did not evaluate levels of sepsis awareness over time. So the key take home messages, public sepsis knowledge is generally low, but it appears to be slowly improving over time. The next thing is the general lack of understanding of sepsis is disproportionate to its substantial mortality rate and global burden. Next, there is a range across time and country and the proportions of people who had heard the term sepsis, could identify sepsis definitions or knew the core signs and symptoms of sepsis. And lastly, there lacks global consensus on a sepsis definition. Of course, this may resolve with further understanding of the pathophysiologist of sepsis, inclusion of data from adults from other geographical locations, such as developing nations, and engagement of a diverse panel of stakeholders when they update the sepsis of definition, the next iteration of an update of the sepsis definition. And there are some future considerations that we took home from this scoping review, is media and internet is a predominant source of sepsis information. Awareness campaigns should consider, and they do consider already using media and internet as a source of information for the public. However, we wanted to caution that the quality of content should always be considered to ensure it is presented in a way that is understandable, actionable, and readable to the general public. Public is more likely to look for sepsis related information when high profile sepsis related stories are published. So celebrity deaths or healthcare system errors. So really this is an opportunity to raise sepsis awareness by embedding information about risk factors, signs and sepsis and mortality in sepsis related news stories. And last, local data is important. This will identify the local knowledge gaps and preferences for the receipt of sepsis information. Thank you very much for your time to attend this webcast. I'm going to pass it back to Tony for questions from the audience. First of all, thank you both to Stantlana and Carla for some wonderful presentations. I have a lot to digest here. And this is just a reminder for the audience. At any time, feel free to type into the question boxes any questions you would like to have asked during the question and answer session. And this is my first question for Stantlana. In your study in the systemic review, it looked like a lot of the information was published between 2012 and 2021. Specifically looking in the next 10 years, how do you think health information technology will change for the better, especially for the early detection of deterioration? And I think it's something we probably all see now that we are getting into MARs that they're being refined over time and hopefully being a little bit more user-friendly, at least where I practice it is. So I was just wondering, what do you think we're going to see in the next 10 years? Yeah, thank you for this question. This is a very good question. I saw the recently published systematic review on the emergency department patients that compared clinical judgment with risk certification models in prediction of ICU admissions and adverse events. And clinical judgment still works better. So I think health information technology will develop and it will be more and more clear shift from simple alerts to smart decision support systems, which not only warn clinicians about potential deterioration, but also propose specific solution for this deterioration like checklists, clear recommendations and algorithms. And also I think in the next 10 years, we will need more sensors like accelerometers, cameras, et cetera, to capture the things that are not captured in the EMR. Thank you. Well, thank you. And just with your answers, it seems to me that we should be starting to use our health information technology better. And like when we go over patient safety reports or event reports or near misses, whatever we call them at our institution, we should probably also try to get some information. Is there something we can glean from that as an added layer to help with our continuous quality improvement? Yeah, I agree with you. I think that's something in the near future we're gonna have to start to think about more and more, but I think that's a very point bringing up in your presentation. So thank you very much. And now this question is for you, Carla. Were you kind of surprised at least looking at even different healthcare professionals that their awareness of sepsis was different versus if you're a physician or a nurse versus not? And what ways should we be addressing this? Well, that is a good question. I think what we were maybe a little surprised by, and this is just with being a newer in the field, is that there was few studies that described EMT knowledge, but those that did show that there was kind of a range of EMT knowledge of those pre-hospital personnel, and that there was kind of identifying a gap there. But we were kind of careful not to draw hard conclusions on this because there were so few studies. But that being said, this is not new. There was a survey that was released by Sepsis Alliance that conducted a survey with EMTs in particular, and also described this gap too, that EMT confidence is generally low in identifying sepsis and awareness of the early signs of sepsis. So to answer your second question, how do we move forward? And perhaps I'll just share what we're doing from the Canadian and, well, I should say North American context is a team within Sepsis Canada led by Drs. Carter at Dalhousie University and Dr. Bigam at Stanford University. They are aiming to address these gaps in sepsis care, and not just with EMTs, but also emergency department staff. And their work aims to improve in the subpopulation early identification and shorten the time to treatment of patients with sepsis. And they're using mixed methods just to really understand kind of what we drove home with the scoping review to understand the local system barriers and facilitator, because there are existing guidelines that aren't maybe known or being implemented by these pre-hospital technicians. No, I think that's very good to share your experience. And I think too, when we talk about especially definitions of sepsis, and there is such a thing as a more local area, and what we see as types of sepsis, especially in North America, might be inherently different than other parts of the world. If you think about South Asia, for example, they might have more viral things like Dunning fever and stuff that we're never gonna see in Ohio where I practice or probably Calgary that you practice. Currently with global warming, that's a whole different story. And I think as you see, sometimes these differences and causes of sepsis, you might have a different phenotype. And what we see here might be a little bit different than other places that just makes it a very complex problem. And I think not only are you gonna need a bigger definition, you're gonna have to look at more of those local issues. And I'm at least glad that Canada is looking at that in a more local issue than some other places. Thank you very much. You're welcome. Now, I do have another question for you, Svetlana. Why do you think there was no real big difference? And you kind of alluded to in the random drive studies, but you did see some difference in the pre and post studies. And do you think at that timeframe that there's just a lot of education out there and you really do get that Haltern effect with all of that data? Yeah, I think the proposed studies are prone to implementation biases. And there are also many confounders mentioned in my presentation, including Haltern effect, which can affect the results and the association with improved outcomes, maybe more positive due to these confounders and due to co-interventions and quality improvement initiatives rather than health information technology implementation. And at the same time, this difference in the results may be also due to the fact that randomized trials could have bad compliance with health information technology implementation because it was in real time in two different settings. And it may cause no effect on mortality in majority of these controlled trials. Thank you. No, thank you very much. I think that's something that you might've seen, at least when we're talking about sepsis with the Dr. Rivers early trial versus some of the later trials, they seem to be doing everything already. So I think there is some continuous quality improvement. I think one of the things it seems like it's coming out at least to me is we have to make sure that our electronic records, we're making sure we're putting accurate and timely information and it needs to be user friendly. And we probably need to focus on that aspect. And then as we get better, start adding things in there. Cause it seems like it's a very complex problem, at least here where I practice. Yeah, thank you. And then finally, I have one more question for you, Carla. Do you know, especially why do you think there's such a disparity in public knowledge between countries? And do you think it might be differences of what is being taught, especially in middle and high schools with health classes and et cetera? That is a good question. So I think part of the issue, maybe this is from the Canadian context I'm coming from, sepsis has not been a priority for many healthcare authorities until the WHO adopted a resolution in 2017 to improve the prevention, identification and management of sepsis. So this is actually what prompted the creation of Sepsis Canada. So, and not just in the published literature, but just even going on the work that some of these organizations have done, they're the countries that put forth the efforts to improve sepsis awareness with high profile campaigns. So Germany, USA, the UK, they typically report a higher awareness of sepsis. So I think this is why there is that disparity. I mean, Germany is the country that actually flagged the WHO that maybe they should be considering sepsis. As a global issue. But I do think the scoping review suggests that these organized efforts that are ongoing may be contributing to greater awareness and knowledge. Per your, what was the second question? Do you mind asking it again? Do you know if there's any data, if there's any differences, especially like you said in Germany of what's being taught in high school or secondary school? Yeah, and that's another good question. So just going back to the scoping review, we know some members of the public, and these studies are from Europe, including Germany. They get their information from school, but there wasn't many details if it's from high school or not. But we do know that a lot of, there are school-based campaigns that are from the UK Sepsis Trust. And I know there's independent groups, I think from the US, and they created some sort of curriculum guidance related to World Sepsis Day that they encourage people to bring. But I think that's an important place to improve sepsis awareness. Really, health is being taught in school as part of the curriculum. And it's a possibility that if children learn about it in school, they'll take these life-saving lessons home. And we know this is possible. One of the best shared campaigns in the literature is that FAST campaign related to stroke. And they released a FAST Heroes Stroke Prevention Campaign to at schools. And I don't think it should be just high schools. I think it should be from elementary onwards, whatever is age appropriate. Yeah, no, I completely agree. I think it's somewhat funny now that my niece is in eighth grade that she starts asking me some of these questions. Did you know this, Uncle Tony? And of course I said, yes, I do. But I think it's very good. And telling you what to do if you find someone on the ground or they're bleeding. So I definitely think sepsis is something we should be teaching in school. So thank you. And then I have one more last question for you, Svetlana, from the audience. And it was, how would you design a trial on a new prediction model? Would it be a randomized control trial, pre-post, staggered implementation, other? Our group have some experience in doing randomized control trials on the health information technology implementation and pre-post studies. I believe now we will better do the pre-post studies to compare the health information technology. And it will be associated not only, it will include not only health information technology, but as I mentioned, kind of smart decision support system to improve the identification of patient deterioration in the ICU. Well, thank you very much. And yet again, I wanna thank both Svetlana and Carla and the audience for attending today's presentation. Again, for anyone who joined us today, you will receive a follow-up email that will include an evaluation. Please take the five or so minutes to complete the evaluation. Your feedback is greatly appreciated. And on a final note, please join us for our next Journal Club, Critical Care Medicine on Thursday, September 22nd. And that concludes today's presentation. Thank you.

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Critical Care Medicine

health information technology

patient deterioration

mortality

length of stay

sepsis awareness

knowledge