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F A L L 2 0 1 6 • V O L U M E 5 2 • N U M B E R 4

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PM 40012961

EDITORIAL

COMMENTARY

PRACTICE GUIDELINE

RESEARCH ARTICLES

Message from the Editor-in-Chief

We’re not making evidence-based decisions: Introducing a tool to assess strengths and weaknesses in healthcare providers

Advisory workgroup recommendations on the use of clinical simulation in respiratory therapy education

A partnership for Indigenous knowledge translation: Implemen-tation of a First Nations community COPD screening day

High-flow nasal cannula therapy for patients with blunt thoracic injury: A retrospective study

EDITOR-IN-CHIEF CANADIAN SOCIETY OF RESPIRATORY THERAPISTS

BOARD MEMBERS

OFFICES

DEPUTY EDITOR

ASSOCIATE EDITORS

EDITORIAL BOARD

ADVISORY MEMBER – STATISTICS

MANAGING EDITOR

Andrew West, EdD(c), RRT, FSCRT, Assistant Professor and Head of Respiratory Therapy, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB

Andrea White Markham, RRT, CRE, Director, Education, Canadian Net-work of Respiratory Care, Toronto, ON

Kathy F Spurr, BSc, RRT, MHI, FCSRT, Assistant Professor, School of Health Sciences, Dalhousie University, Halifax, NS

Edita Almonte, MS, RRT-NPS, Manager of Respiratory Therapy and Neurodiagnostics, Tawam Hospital, United Arab Emirates (in affiliation with Johns Hopkins International)

Valerie Banfield, MN, RN, CNCC(c), Faculty, Critical Care Nursing Program, Registered Nurses Professional Development Centre, Halifax, NS

John Davies, MA, RRT, FAARC, Registered Respiratory Therapist and Clinical Research Coordinator, Duke University Medical Center, Durham, NC

Emily Etcheverry, BOT, MEd, PhD, Professor and Senior Scholar, College of Rehabilitation Sciences, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB

Robert Gilbert, PhD (Pharm), Assistant Professor, QEII/Dalhousie Univer-sity, Halifax, NS

Lori Hand, BSc, RRT, CCRA, Research Coordinator, McMaster University, Senior Staff ICU Respiratory Therapist, Hamilton General, Hamilton, ON

Jeffrey M Haynes RRT RPFT, Clinical Coordinator at Pulmonary Function Laboratory, St. Joseph Hospital, Nashua, NH

Wrae Hill, MSc, RRT, FCSRT, Human Factors and System Safety, Medicine & Quality - Interior Health, Kelowna, B.C. , Adjunct Professor University of British Columbia – Okanagan

Thomas Piraino, RRT, Clinical Educator, St. Joseph’s Healthcare, Assistant Clinical Professor (Adjunct), Department of Anesthesia and Critical Care, McMaster University, Hamilton, ON

Peter J Papadakos, MD, FCCM, Director, Critical Care Medicine, Professor, Departments Anesthesiology, Surgery and Neurosurgery, University of Rochester, Rochester, NY

Justin Sorge, RRT, MPH, Laboratory Surveillance & Outbreak Coordinator, BC Centre for Disease Control, Public Health Laboratory, Vancouver, BC

Marco Zaccagnini, BHSc, RRT, Department of Anesthesia & Critical Care, McGill University Health Centre, Royal Victoria & Montréal General Hospital, Montréal, QC

Jason Zurba, BSc, RRT, Clinical Supervisor, Respiratory Therapy, Royal Columbian Hospital, New Westminster, BC

Doug Staley, BScEE, MA, Office of Clinical Research, St. Boniface Hospital/University of Manitoba, Winnipeg, MB

Carly McCuaig, Ottawa, ON

Jason Nickerson, RRT, FCSRT, PhD, Bruyère Research Institute, Ottawa, ON

The Canadian Society of Respiratory Therapists provides national leadership through advocacy, service and unity to respiratory therapists in Canada. Established in 1964 as the Canadian Society of Inhalation Therapy Technicians, the CSRT is the national professional association that represents over 3500 respiratory therapists across Canada and promotes exemplary standards of practice, conduct and performance in the provision of respiratory care. The CSRT is also the credentialing body for RTs who practice in non-regulated jurisdictions and administers the accreditation process for respiratory therapy education programs. For more information, please visit: www.csrt.com

Patricia-Ann Therriault (Quebec), Elizabeth French (Alberta), Edouard Saadé (Saskatchewan), Scott Vigliotti (British Columbia), Paul Williams (Ontario), Dave Sahadeo (British Columbia)

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Can J Respir Ther Vol 52 No 4 Fall 2016 99

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editoriAL

CommentArY

reseArCh ArtiCLes

PrACtiCe GuideLine

Message from the Editor-in-Chief 103

Jason W Nickerson

We’re not making evidence-based decisions: Introducing a tool to assess strengths and weaknesses in healthcare providers 104

Kathleen F Spurr, Kelly Lackie, Robert Gilbert

A partnership for Indigenous knowledge translation: Implementation of a First Nations community COPD screening day 105

Cory Leanne Bendall, Danielle Marie Wilson, Kelly Rose Frison, Jessica Ann Inskip, Pat G Camp

High-flow nasal cannula therapy for patients with blunt thoracic injury: A retrospective study 110

Meghan E Halub, Sarah K Spilman, Kristina A Gaunt, Keith D Lamb, Julie A Jackson, Trevor W Oetting, Sheryl M Sahr

Advisory workgroup recommendations on the use of clinical simulation in respiratory therapy education 114

Irina Charania, Karl Weiss, Andrew J West, Seana Martin, Manon Cook, Roger Cook

F A L L 2 0 1 6 • v o L u m e 5 2 • n u m b e r 4

100� Can�J�Respir�Ther�Vol�52�No�4�Fall�2016

MESSAGE FROM THE EDITOR-IN-CHIEF

I want to begin what will be my last message asEditor-in-Chief by saying a simple “thanks” toeveryone who has worked so very hard to make ourJournal what it is today—our Editors, Peer Reviewers,Authors, Editorial Board, and Managing Editor havedone a tremendous job in bringing the journal towhere we are, and for that I will be forever grateful.Thank you.

There are certain liberties afforded to the Editor-in-Chief, one of them being the ability to write andpublish editorials on topics of personal interest orconcern and a certain creative license to try andpush new ideas for how the profession and the jour-nal can bring the best care possible to our patientsand deliver needed improvements to our healthcare systems. I want to share some reflections tohelp guide the next generation of leaders within the profession: some ofyoumay be students, some of youmay bemid-career respiratory therapists,and others with decades of experience and expertise may be looking for anew challenge. The point is not where in your career you are, it is aboutwhat challenges you are willing to take on, how reflexive and responsiveyou can be in adapting to and promoting new ideas, and how truly reflec-tive you can be about your professional practice and the role of respiratorytherapists in driving innovation in our health systems and the best possi-ble care for our patients.

As respiratory therapists, we are given a tremendous privilege to sitwith our patients and their families, often during times of crisis. We areone of the few professions who, upon entry into practice, are affordedthe opportunity to work with some of the sickest patients in Canada, aresponsibility that demands not only a clinical acumen but also the abilityto empathise and reflect on issues that confront our senses and ethics.This is a heavy burden, but I truly believe that it is a privilege to be invitedto play such a seminal role in a person and a family’s life, and one thatnone of us takes lightly. My advice here is to reflect not only on whatimmediately confronts you in a visceral sense, and to situate your under-standing of our patients not only in the context of their medical needs,but also in the moral and social worlds that they create and that influencethem and their health. Sit with your patients, learn from them and theirfamilies, and use this knowledge to drive change socially, politically,clinically—wherever you might find it—in meaningful ways. To be able tocare for so many truly insightful people and to learn from their lives isat the heart of both providing patient-centered care and learning from it.

The role of an entity like the Journal can be broken down into both thespecific–to publish research, commentary, and other articles that influ-ence practice—and the difficult to measure such as driving professionalengagement and creativity. But, ultimately what we as researchers, investi-gators, and inquisitive minds do is challenge the status quo and demandsomething better. Research is not about article metrics or the number ofpublications, it is about driving inquiry and asking difficult questions.

Quality improvement rejects the idea that“better” is the enemy of “good enough”. Ourprofession and our patients demand more,and it is incumbent upon us to work towarddelivering not only the highest quality patientcare, but also the best health systems that bal-ance prevention with reaction and the policyframeworks that ensure the benefits of healthinnovations are shared equitably among allmembers of our population. To that end, I chal-lenge you to reject the apathy that too oftencreeps into professional lives and allows us tosettle into careers or patterns or systems thatare comfortable, but unambitious. Be part ofsomething that is bigger than yourself, yourdepartment, or your profession and change

things for the better. Challenge the world and be bloody-minded whenthe situation demands it, but be driven by purpose.

Finally, while much of the clinical work that we do as respiratorytherapists takes place in a hospital, our patients’ lives take place largelyoutside of these walls. Their health, families, friends, and moral andsocial worlds all exist beyond the boundaries of our hospital, and tounderstand the true social determinants of our patients’ health, wehave to bring respiratory therapy to the community. This is not solelyabout engaging respiratory therapists in primary care or communitycare; it is about pushing ourselves and our profession to understandand engage the communities where we work and what influences theoptions and choices that our patients are able to make. The world is avery big, interesting place—understand as much of it as you can anduse that to influence the care that you provide and to shape the policiesand practices that have importance to you, your patients, and your com-munity. Do not settle for what is easy or comfortable. Confront theobstacles. Understand the challenges of life in a rural community, forCanada’s indigenous people, for the homeless, for immigrants and refu-gees, for people who use drugs, for people in low- and middle-incomecountries. Hear their stories and find ways to work with them to improvetheir health and the systems that we all depend on. Keep exploring.

I want to thank you all for allowing me to embark on this journey asEditor-in-Chief. I have learned so much about what it truly means to be arespiratory therapist over these years. It has been a fascinating opportuni-ty to learn from you and to work with you to build capacity in our profes-sion to research and understand respiratory health in Canada andaround the world. This profession has a tremendous number of peoplewith immense talent that I know are doing important things—thankyou for allowing me to have been a part of that.

Jason W Nickerson RRT FCSRT PhD, Editor-in-Chief

Jason W Nickerson

Correspondence: Dr Jason W Nickerson, Bruyère Research Institute, 308B – 85 Primrose Avenue, Ottawa, Ontario K1R 7G5. Telephone 613-562-6262,e-mail [email protected]

This open-access article is distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC) (http://creativecommons.org/licenses/by-nc/4.0/), which permits reuse, distribution and reproduction of the article, provided that the original work isproperly cited and the reuse is restricted to noncommercial purposes. For commercial reuse, contact [email protected]


mailto:[email protected]

COMMENTARY

We’re not making evidence-based decisions:Introducing a tool to assess strengths and weaknesses

in healthcare providersKathleen F Spurr BSc RRT MHI FCSRT1, Kelly Lackie PhD RN2, Robert Gilbert PhD (Pharm)1

In an ideal world, respiratory therapists (RTs) would use the evidence-based decision-making (EBDM) process to identify, appraise, and inte-grate new research evidence with clinical expertise and patient values tooptimize patient care [1]. Competence in this process is essential to thedevelopment of best practices, programs, policies, services, and clinicalpractice guidelines that are current, evidence-based, maximally effective,and affordable. Lack of knowledge of the EBDM process or failure toapply it in practice may lead to the delivery of suboptimal or even ineffec-tive treatment, poor patient outcomes, provision of unnneccessarilyexpensive services, and decreased patient quality of life [2, 3].

The need for EBDM competency is justified with the explosionof new knowledge pertaining to respiratory care in recent years and thechallenges respiratory care professionals have faced in integrating thisknowledge into practice quickly [4]. To demonstrate the challenges weface, one only needs to consider that since 2006 there have been approx-imately 30,000 English, peer-reviewed published studies pertaining tomechanical ventilation. It is not acceptable or realistic to rely solely onthe sporadic and limited efforts of external bodies (societies, academics)to translate such knowledge for us. In fact, the timely closing of knowl-edge to practice gaps requires the collective effort of all respiratory careproviders. The judicious integration of emerging knowledge transformsthe way in which we care for individuals affected by respiratory disorders.Therefore, the more people we support in becoming proficient and con-fident in EBDM, the easier it will become to achieve our goals of timely,safe, and efficient integration of new knowledge into our practices.

There are significant gaps between what we know (best available evi-dence) and what we do (clinical practice) [4]. EBDM is an entry levelcompetency for today’s graduate RT; however, the majority of currentypracticing RTs were educated prior to this becoming a requirementand therefore, did not receive education in all components of theEBDM process. Consequently, many RTs do not possess comprehensiveknowledge and skills (i.e., the ability and confidence to find, appraise,integrate, and implement new knowledge into practice) required ofEBDM practice [5–8]. To support RTs in attaining full EBDM competen-cy, we first need a better understanding of where their shortcomings are.To facilitate such understanding, a tool for assessing comprehension ofthe EBDM process (Halifax ACE Tool) for practicing healthcare profes-sionals has been created [8].

The Halifax ACE tool, developed using a Delphi process, consists of26 multiple-choice questions evaluating understanding of the five com-ponents of EBDM: (i) developing a clinical question, (ii) developingand implementing an appropriate search strategy for finding knowledge

specific to the clinical question, (iii) identifying sources of evidence(internal and external), (iv) appraising knowledge for its validity andappropriateness to the clinical question, and (v) integrating (synthesizing)evidence. Knowledge and use of EBDM was then evaluated throughpilot testing with individual healthcare providers from six differentprofessions, including respiratory therapy. This work demonstrated aneed for knowledge and skill development in various components ofEBDM across these healthcare professions.

Having established content validity, the Halifax ACE Tool providesan opportunity for RTs wanting to assess their EBDM knowledgeand skills. It is also a resource to support organizations (i.e., regulatorybodies, governments, and healthcare institutions) in the creation of con-tinuing education programs that support the development of EBDMcompetency across the health professions. By improving RTs’ confidenceand ability in the EBDM process, knowledge-to-practice gaps will bereduced. The Halifax ACE tool and resources for supporting the devel-opment of EBDM skills in practising professionals are available for usefree of charge. These resources can be accessed by contacting theauthors.

REFERENCES1. Straus S, Glasziou P, Richardson S, Haynes B. Evidence-Based Medicine:

How to Practice and Teach It. Edinburgh: Churchill Livingstone; 2009.2. Lizarondo L, Grimmer-Somers K, Kumar S. A systematic review of

the individual determinants of research evidence use in allied health.J Multidiscip Healthc 2011;4:261–72. doi: 10.2147/JMDH.S23144.

3. Lenfani C. Clinical research to clinical practice – Lost in translation?N Engl J Med 2003;349:868–74. doi: 10.1056/NEJMsa035507.

4. Restrepo RD. AARC clinical practice guidelines: From “reference-based”to “evidence-based.” Respir Care 2010;55:787–9.

5. McGlynn EA, Asch SM, Adams J, et al. The quality of health care deliv-ered to adults in the United States. N Engl J Med 2003;348:2635–45.doi: 10.1056/NEJMsa022615.

6. Straus S, Tetroe J, Graham ID. Knowledge translation in health care:Moving from evidence to practice. Oxford: Wiley-Blackwell; 2009.

7. Murphy M, MacCarthy MJ, McAllister L, Gilbert R. Application of theprinciples of evidence-based practice in decision making among seniormanagement in Nova Scotia’s addiction services agencies. Subst AbuseTreat Prev Policy 2014;9:47. doi: 10.1186/1747-597X-9-47.

8. Spurr K, Dechman G, Lackie K, Gilbert R. Creation of a tool for assessingknowledge in evidence-based decision-making in practicing health careproviders. J Contin Ed Health Prof 2016;36:164–70. doi: 10.1097/CEH.0000000000000083.

1School of Health Sciences, Dalhousie University, Halifax, NS; 2RN Professional Development Centre, Halifax, NSCorrespondence: Kathleen F Spurr, Assistant Professor, QEII/Dalhousie School of Health Sciences, 1276 South Park St., Room 668, Bethune Bldg, Halifax,

NS, B3H 2Y9, e-mail [email protected]



http://dx.doi.org/10.2147/JMDH.S23144http://dx.doi.org/10.1056/NEJMsa035507http://dx.doi.org/10.1056/NEJMsa022615http://dx.doi.org/10.1186/1747-597X-9-47http://dx.doi.org/10.1097/CEH.0000000000000083http://dx.doi.org/10.1097/CEH.0000000000000083mailto:[email protected]

RESEARCH ARTICLE

A partnership for Indigenous knowledge translation:Implementation of a First Nations community COPD

screening dayCory Leanne Bendall BHSc (RT) MPH (HP)1,2, Danielle Marie Wilson MPH2, Kelly Rose Frison BHSc (RT)2,

Jessica Ann Inskip PhD3,4, Pat G Camp BSc(PT) PhD3,4,5

CL Bendall, DM Wilson, KR Frison, JA Inskip, PG Camp. A partnership for Indigenous knowledge translation: Implementation of a FirstNations community COPD screening day. Can J Respir Ther 2016;52(4):105–109

ABSTRACT

This article suggests a method for integrating the principles of Aboriginal knowledge translation (KT) in the implementation of a pilot for chronic obstruc-tive pulmonary disease (COPD) screening to improve current practice and provide health programming that is culturally sensitive and relevant. The ele-ments of the Consolidated Framework for Implementation Research model guided a community informed design for the Lung Health Day that wasplanned with two communities of the Secwepemc Nation in British Columbia. By integrating the principles of Aboriginal KT, program implementationdesign can address the current disparities in respiratory care and management of COPD and improve the health status of First Nations patients.

Key Words: Aboriginal health; First Nations; knowledge translation; knowledge exchange; implementation; chronic obstructive pulmonary disease

Terms used to describe the Indigenous people of Canada

In this research, the terms “Aboriginal” or “Indigenous” have beenused to refer inclusively to all three Indigenous populations inCanada: First Nations, Métis, and Inuit. The use of terminology isevolving. The term “Aboriginal” has less favor due to its historicalimposition by colonizing governments. To be consistent with cita-tions from previously published literature the term “Aboriginal”has been repeated only in the context that refers to the original refer-ence [1].

INTRODUCTIONSmoking is the primary cause of chronic obstructive pulmonary disease(COPD) in Canada [2]. The prevalence of smoking in the Aboriginalpopulation is almost twice as high as the non-Aboriginal population(39% vs. 20.5%, respectively) [3]. As a result, Aboriginal Canadiansshoulder a large burden of health-related illness due to the effects ofsmoking [2, 4–6]. Ospina et al. [2] recently reported a higher incidenceof new cases of COPD among a First Nations cohort compared to anon-First Nations comparison group (incidence rate ratio of 2.1; 95%CI; 1.97, 2.27). Correspondingly, in their study the prevalence ofCOPD in the First Nations population was approximately 2.4 timeshigher than the non-First Nations cohort [2]. There is an increasedneed for COPD-related health services in First Nations communities;however, services are either not available or are not accessed by this pop-ulation [6]. Therefore, more effective programming is required to addressthe lung health needs of First Nations communities in Canada.

Many Aboriginal people have experienced, and continue to experi-ence, cultural alienation and multi-generational trauma from residentialschool incarceration [7]. Economic and political marginalization and rac-ism also erode resiliency and the ability to maintain health and well-being[7]. Thus the residual aspects of colonization magnify the impact of keysocial determinants of health. Financial need, food insecurity, reduced

educational opportunities, social isolation, and poor housing conditionspotentiate the COPD risk factors of tobacco use and childhood exposureto second-hand smoke in the Aboriginal population [2]. Research com-pleted by the Wellesley Institute [8] details systemic racism in the Cana-dian health system. This is supported by the findings of the Truth andReconciliation Commission where all levels of government are asked“… to acknowledge that the current state of Aboriginal health in Canadais a direct result of previous Canadian government policies including res-idential schools…” [9, p. 2]. The Indigenous population has current andhistorical health care experiences that mirror the previous trauma andneglect of institutional care (including residential schools and child wel-fare practices) [9]. These experiences reduce individual confidence in thecare they receive and may create reluctance to seek treatment [9].

Aboriginal people in Canada may also experience inconsistent careand management once faced with a diagnosis of COPD when comparedwith non-Aboriginal patients with COPD [5, 6, 10]. Sin et al. [6] reporteda differential use of health care services for COPD between Aboriginal andnon-Aboriginal patients that was not explained by socioeconomic status orliving location. They reported that Aboriginal patients experienced gaps inCOPD care and treatment, and were 55% (95% CI; 52%–58%) less likelyto see a specialist and 66% (95% CI; 63%–70%) less likely to undergo spi-rometry than non-Aboriginals [6]. These results highlight the need for anassessment of how health care providers (HCPs) approach care, includinghow stereotyping and bias may unconsciously limit the care and treatmentoptions for Aboriginal respiratory patients [8].

Gaps in care hinder respiratory health. There are numerous knowledgetranslation (KT) strategies that aim to increase uptake of research-basedclinical practice to ultimately improve the health outcomes for patients[10, 11]. However, to facilitate uptake into practice in a First Nations con-text, an optimal KT strategy should incorporate principles of Indigenousknowledge sharing, which includes a community-developed approach,experiential knowledge, and an emphasis on oral traditions [7, 11, 12].Strategies to improve respiratory care that integrate the principles of Indig-enous KT may have the greatest potential to address existing health status

1Department of Physical Therapy, UBC, Vancouver, British Columbia, Canada; 2Centre for Heart Lung Innovation, Vancouver, British Columbia, Canada;3St. Paul’s Hospital Pulmonary Rehabilitation Clinic, Vancouver, British Columbia, Canada; 4Michael Smith Foundation for Health Research Scholar,Vancouver, British Columbia, Canada

Correspondence: Pat G Camp, 1081 Burrard Street, Vancouver, B.C., V6Z 1Y6, e-mail [email protected]




inequities and disparities in COPD treatment. This paper describes how aKT strategy that incorporated the principles of Indigenous KT was used toimplement a First Nations community-based screening day in partnershipwith the Adams Lake and Neskonlith First Nations of the SecwepemcNation in British Columbia, Canada.

INTEGRATED KNOWLEDGE TRANSLATIONIt has been estimated that it takes an average of 17 years for 14% ofresearch findings to be adopted into clinical practice [13]. KT uses differ-ent strategies to encourage and support clinicians to embed evidence-based research into clinical best practice to improve patient outcomes.The Canadian Institutes of Health Research define western-medicinebased KT as an “...iterative process that includes synthesis, dissemination,exchange and ethically sound application of knowledge” [11]. However, awestern-based approach to KT may not be relevant in Indigenous healthcare. The scientific method for gathering and disseminating evidence islargely unidirectional from researcher to clinician to patient. In contrast,Aboriginal KT fosters an approach where the researcher, clinician, andthe community are seen as resources for each other [11, 14]. There is amutual sharing of knowledge that is inclusive of a variety of perspectives.Table 1 indicates the components of western-medicine based KT andapplies them in an Aboriginal context. Aboriginal knowledge structuresinclude community voices that illustrate “different ways of knowing”[11, 12, 14–16]. Dr. Jeanette Armstrong, an adjunct professor at the Uni-versity of British Columbia Okanagan and a member of the Syilx Nation,noted in a recent keynote presentation at the 2nd Okanagan CulturalSafety symposium that:

Just as written grammar systems have rules that establish pre-ciseness of meaning, Indigenous languages develop precisenessfrom the understanding that has been established by the peo-ple... who have created information packages that are repre-sented by characters in nature (plants and animals) developedover 12 thousand years of oral tradition. [12]

Thus, in a First Nations context, local understanding is often sharedthrough linguistic constructs such as story, song, or ceremony. This methodfor intergenerational knowledge sharing has supported the health andwellness of Aboriginal people for centuries [11]. While western-medicinebased KT gains academic rigor through iterative scientific method, levelsof evidence, and established research methodologies, Indigenous KTshares best societal practices and social instruction through a system oforal documentation practiced over thousands of years [11, 12].

It is critical that health interventions integrate the principles ofAboriginal KT and align with the community’s geographical, social, cul-tural, and political history [11, 15, 16]. For example, often the four quad-rants of the medicine wheel (physical, emotional, mental, and spiritual)guide the content and context of health interventions considered by

the community when promoting wellness as part of their unique oral his-tory [12]. The final synthesis of the information takes into account thepriorities of the people involved and asks for their contribution to imple-mentation in order to sustain the knowledge and practices within thecommunity. The design and implementation of Indigenous health pro-grams that integrate the principles of Indigenous KT may be more rele-vant, have more emphasis on an equity-focused approach to healthcare, and ultimately may be more successful at improving Indigenoushealth outcomes.

Although in general western-based approaches to KT may not be agood match with Indigenous health and learning values, there aresome existing KT strategies or frameworks with components that do alignwith Indigenous health and learning values. The Consolidated Frame-work for Implementation Research (CFIR) is a model that combines sev-eral implementation theories to create a standardized method forapplying knowledge across diverse contexts [17]. Developed in 2009 byDamschroder et al. [17], it outlines implementation strategies based onfive fundamental components: (i) individual characteristics, (ii) interven-tion characteristics, (iii) inner setting, (iv) outer setting, and (v) the pro-cess of implementation. One component of the CFIR model detailsfive implementation actions to guide KT planning [17] (Table 2). Twostrengths of this model are that it utilizes an approach that focuses onknowledge sharing among all participants and the model componentscan be tailored to the principles of Indigenous KT. The following sec-tions of this article describe how the CFIR was used as the theoreticalfoundation for the Secwepemc Lung Health Day held approximatelythree hours north of Kelowna B.C. in the Adams Lake and Neskonlithtraditional territory.

ACTIONING INDIGENEOUS KNOWLEDGETRANSLATION—SECWEPEMC LUNG HEALTH DAY

The Secwepemc community hosted this opportunity for knowledge shar-ing and actively promoted attendance by all community members. Table3 describes the agenda for the event. The day began with an Elders teach-ing circle for the HCPs and included chronic disease learning sessions.The Chief and her council presented on the community traditions forpromoting wellness and preventative care such as the traditional dietthat is sourced from the land and how seasonal activities maintain theNation’s health through this connection with their land. Lunch was pro-vided by the Elders and all participants continued to share knowledgeand network during the meal. The afternoon contained COPD screen-ing and follow up of the results with the HCPs. The day finished witha participant evaluation and a small gift exchange between the Eldersand the HCPs.

Intervention characteristics—inclusive of multiple perspectivesDamschroder et al. [17] described the first CFIR domain “Intervention”as the characteristics of the intervention being implemented in the orga-nization, and they stressed that it is necessary to adapt the intervention tomeet the needs of the organization, without losing the core componentsof the intervention that are necessary for its success. This approach iswell-matched with the Aboriginal health emphasis on “Being Inclusive

TABLE 1

The process of non-Indigenous and Indigenous knowledgetranslation of research results

Non-Indigenous Indigenous

Identify the problem Establish community trust and partnership toidentify a problem of significance to the people

Analyze the context Recruit culturally competent field workers andcommunity members to inform context and guideall stages of research

Select the knowledge Create ongoing opportunities for knowledgesharing to facilitate collaborative decision making

Select the intervention Commit to return results to communities forverification and validation before widerdissemination, implement the intervention in themost appropriate mode of delivery for thecommunity context

Support the use in practice Communicate results to inform policy andpractice

Adapted from Jardine and Furgal [16] and Hoens et al [19].

TABLE 2

Five implementation actions that support community-established meaning

Actions

Identify stakeholders,prioritize content, and integrate methods for knowledgetranslationCreate a shared vision and recruit internal and external change agents thathave gained community respectRemain faithful to implementation plan created by consensusCreate a safe atmosphere for information sharing, debriefing, and furtheradaptationIdentify formative goals that are S.M.A.R.T. (specific, measurable, attainable,relevant, and timely) from the community’s perspective

Adapted from Jardine and Furgal [16] and Damschroder [17].


Bendall et al

of Multiple Perspectives.” In 2009, Estey et al. [11] emphasized that the“large gaps in our knowledge about all Aboriginal health” would onlybe addressed if health interventions incorporated a “multiplicity of per-spectives”. Interventions characteristics should be legitimate, valid, andadaptable [17]. Legitimacy and validity are related to the communityand the HCPs’ perception of who created the intervention and designfor implementation. For the Lung Health Day it was essential to havethe Secwepemc Elders, First Nation employed HCPs, health authorityHCPs, and the University of British Columbia Family Practice Residents’Supervisor form a planning team to ensure respectful representation ofall stakeholders and to reinforce the legitimacy and validity of the event[16]. Feedback from the community members highlighted the impor-tance of bringing new physicians out into the community to witness,experience, and learn about local First Nation culture and health prac-tices. Adaptability of program components was essential as the stake-holders planned to bring the model for the Lung Health Day to manyof the Secwepemc communities as well as other First Nations communi-ties that are part of the health authority. The Lung Health Day pilot wasevaluated by the participants and the HCPs to improve future events.Success of the event was determined by a participant survey which indi-cated that 100% of participants would recommend participation in arepeat of the community event to friends and family. Evaluations ofthe day were also shared with the planning stakeholders and Secwepemcleadership, who suggested further improvements to the implementationto support sustainability of the KT by creating an online learningmodule.

Inner setting—different sources of knowledge and outersetting–intergenerational knowledge sharingThe second CFIR domain is “Inner Setting,” which relates to the within-organization “structural, political, and cultural contexts through whichthe implementation process will proceed” [17]. It acknowledges that tobe successful, the intervention must acknowledge and incorporate thetangible and intangible networks and lines of communication that existwithin an organization. The CFIR “Outer Setting” domain refers to“the economic, political and social context within which the organizationresides” [17]. In practice, there is overlap between inner and outer set-tings, and these domains closely aligned with the Aboriginal KT concept

of “Different Sources of Knowledge” and of “Intergenerational Knowl-edge Sharing” (8, 12).

Different sources of knowledge can facilitate an optimal climate forimplementation by contributing to the social architecture, methods ofcommunication, and opportunity for cultural recognition [17]. The foun-dation of the Lung Health Day’s inner setting were the health authorityHCPs who were comfortable with their established divisions of labourand professional scope of practice, but who also looked for opportunitiesfor coalitions of service with this First Nations community [14]. Theinner setting for the Lung Health Day also relied on existing receptivityto health learning within the Adams Lake and Neskonlith First Nationstheir role in adjusting the day’s content to improve community engage-ment; and the link of the event with the community priorities for addic-tion awareness, prevention, and treatment.

The planning team also felt that the lung health day could create a set-ting for intergenerational knowledge sharing and cultivate learning aboutsmoking and the risk of developing COPD. However, this componentwas difficult to implement. Although the health authority team partici-pated in a recent student health fair to promote lung heath with the com-munity youth, it became apparent that more emphasis on this youngerpopulation would be required to address the community priorities andreflect a service partnership that was truly patient and communitycentred [11]. As the Lung Health Day was targeted to coincide with theSecwepemc Addiction Awareness week and World COPD Day 2014,there was only a small window of time for relationship building relatedto lung health for the community’s youth [16], and would require addedresources to increase the scope of the lung health day to includeprevention.

Individual characteristics—mutual sharing of knowledgeThe fourth domain of the CFIR framework is the “Individual”, whichrefers to the unique characteristics of the people involved in the imple-mentation. It recognizes that individuals make choices, experimentwith interventions, and influence others [17]. This domain aligns withthe Indigenous KT principle of “mutual sharing of knowledge”, whichalso emphasizes the importance of including the perspectives of the mul-tiple stakeholders of the event. To formalize the importance of the mutu-al sharing of knowledge, the Secwepemc Lung Health Day relied on the

TABLE 3

Event schedule

Time Component Description

08:30–10:30 Community teach-back to HCPs Session opened by drum song and prayerElders held discussion circle for HCPs on respectful approach to care, healing traditions, building relationships,and end-of-life traditionsPermission was received to record the session to create online cultural safety resource

10:30–11:00 Break Reflect on what was sharedIntroduce HCPs to community members who were now arriving

11:00–12:00 Chronic disease learning sessions(15 minute presentations)

Traditional tobacco use and the importance of community in health—IH Aboriginal Tobacco CoordinatorCOPD management, physiology overview, signs, symptoms, and breathing techniques—IH KnowledgeCoordinatorChronic co-morbid disease associated with COPD—Family Practice ResidentAnxiety and depression and community contacts—IH Mental Health Services

12:00–1:00 Chief and Council presentationand lunch

Community traditions of preventative care and seeking information to support wellnessPrayer of thanksLunch of traditional food prepared by the EldersSharing food as part of knowledge transfer

1:00–3:00 COPD screening COPD-6 device used to screen all participantsAbnormal screening results follow-up with screening Spirometry stations with Family Practice resident andRRT consultationsResources set up for smoking cessation and COPD management including mental health and substance useissues

3:00–4:00 Wrap-up and gifts Band RN spoke with all participants and reviewed recommendations and plan for follow upIH Aboriginal Practice lead initiated short evaluation of the day with participants before they leftFood to take home offered to allSmall gifts exchanged between Elders and HCPs

Note: HCP, health care provider; IH, interior health; COPD, chronic obstructive pulmonary disease; RRT, Registered Respiratory Therapist; RN, Registered Nurse.


A partnership for Indigenous knowledge translation

relationship that had been established between the Adams Lake and Nes-konlith First Nations and the Government of British Columbia’s InteriorHealth (IH) Authority via a letter of understanding. This letter describedthe collaborative relationship between the First Nation and the IHemployees to inform the components of the day and clearly describedhow the mutual sharing of knowledge would be facilitated. One key fea-ture of the sharing of knowledge was the use of a talking circle with thecommunity Elders. The talking circle gave the HCPs time with the Elderswho shared their knowledge of culturally appropriate approaches tobuilding care relationships such as mutual sharing of family history.This approach strengthened the credibility of the day as the Neskonlithchief and council members presented on the importance of preven-tion and appropriate care in sustaining the health of the people,and how seeking and sharing knowledge has ensured the well-beingof the community [12].

Process of implementation—community established meaningThe final domain of the CFIR focuses on the “Process of Implementa-tion” [17]. Process is recognized as having many components whichmay be happening simultaneously or in a non-linear fashion. This domainis reflected in the Indigenous KT concept of “community-establishedmeaning,” which emphasized that the creation of the lung health daywas transparent and included multiple stakeholders from the healthauthority, the community health workers, and the Elders. There was alsoan emphasis on discussing the event, revisiting the main objectives of theday, and revising as new suggestions arose.

Evaluation and knowledge disseminationEvaluation of the day was completed using participant and provider sur-veys that were collaboratively developed by the community-based plan-ning team. Fifty-five of 800 First Nation community members came tothe event (7%). Forty-four individuals were screened for COPD usingthe COPD-6™ (Vitalograph, Hamburg, Germany) device which mea-sures forced expiratory volume in one second (FEV1), forced expiratoryvolume in 6 seconds (FEV6), the FEV1/FEV6 ratio, and the percent ofpredicted values, as well as a calculated obstructive index or lung age.Twenty-six participants completed an evaluation at the end of the day.As well, an online HCP survey completed one week after the eventallowed the event organizers to gain insight as to how the program designcould be improved and possibly adapted for other chronic diseases. Asummary of the survey results was presented to the Secwepemc NationLeadership Council in January of 2015, and the HCP surveys wereshared with the Neskonlith and Adams Lake First Nation health direc-tors for future use.

The screening day identified 10 individuals who required spirometrytesting and follow-up with their family physicians. All the testing resultswere submitted for IH respirologist interpretation, and the results andinterpretations were sent to patients’ family physician or communitynurse practitioner. The screening day exposure has helped increaseawareness of chronic lung disease in the community and the HCPshave been asked to repeat the screening day with different communitieswithin the Secwepemc Nation.

DISCUSSIONIndigenous health care principles use a community-focused approach toensure that care is based on building relationships and fostering trustwithin the health system as well as addressing the reasons behind a reluc-tance to seek care [8, 18]. This social approach to care may not be wellsuited to western-based KT strategies that tend to target a specific medicalaudience without necessarily understanding of the context within whichhealth care takes place. The integration of the principles of IndigenousKT with those of western-medicine based KT creates an opportunity tocontextualize health care and, in so doing, may address racial inequalitiesas they relate to COPD management [18].

The high prevalence of Indigenous tobacco use often results in anincreased need for healthcare services over time. This burden may be fur-ther amplified in the Indigenous populations if there is a lack of diagnos-tic services or reluctance to seek care because of structural racism in the

health system. To combat this, a COPD screening day that was developedfor and by First Nation peoples relied on approaching the community asequals and used a knowledge translation framework that incorporatedIndigenous KT principles. This model for implementation created pro-cesses that were adaptable and balanced standardized evidence-basedcare with community informed priorities for health.

Specifically, the community members were acknowledged as expertsin their knowledge of the people, culture, wellness, and health traditions;instead of a unidirectional approach, there were opportunities to developa day that was based on the knowledge held by all the stakeholders.

LIMITATIONSThis paper describes the pilot COPD screening day held in one FirstNations community in British Columbia. In general, Aboriginal knowl-edge is developed by the community over time. This increases communityengagement and uptake into practice. Different First Nations may havedifferent approaches to learning, collaboration and health care so theapproach we used may not be transferable to other communities [14].Sustainability relies on maintaining collaborative relationships where allstakeholders can inform further health initiatives based on evolving com-munity priorities. However, health system pressures challenge sustainabil-ity. As local health authorities are funded based on changing systempriorities, it is not clear if future screening days will be funded, and com-munity partners may see this as a lack of commitment to advance Aborig-inal health, reduce treatment disparities, and apply Indigenous KT.

CONCLUSIONQuantifying the current respiratory health status of Canada’s Indigenouspopulation is limited due to sparse data compared to the Non-Indigenouspopulation. Further research is required to address community identifiedbarriers to effective, appropriate, accepted, accessible services that pro-mote improved culturally safe, health outcomes for Indigenous people.Integrating Indigenous KT into program implementation is one way toeffect change in the health system, and amend the approach to care forIndigenous patients. Our experience suggests that by integrating the prin-ciples of Indigenous KT, program implementation can begin to addressracial and ethnic disparities in current respiratory care and managementof COPD. Ultimately, we believe that incorporating the principles ofIndigenous KT as part of health programming design and implementa-tion will improve evidence informed practice for Indigenous patientswith chronic respiratory illness.

ACKNOWLEDGEMENTS: The authors would like to thank the peopleof the Secwepemc Nation who participated in this event and the key indi-viduals who felt strongly about promoting lung health within the com-munity including the health director for the Neskonlith First Nation,Ms. Jody Leon, and the health director for the Adams Lake First Nation,Ms. Shirley Anderson.

REFERENCES1. National Collaborative Centre for Aboriginal Health. Landscapes for

First Nations, Inuit, and Metis Health: An Environmental Scan of Orga-nizations, Literature and Research. Prince George, BC: National Collab-orating Centre for Aboriginal Health; 2014, pp. 6–19.

2. Ospina MB, Voaklander D, Senthilselvan A, et al. Incidence and preva-lence of chronic obstructive pulmonary disease among aboriginal peoplesin Alberta, Canada. PLoS One 2015;10(4):e0123204. doi: 10.1371/journal.pone.0123204.

3. Physicians for a Smoke-free Canada. Smoking among Aboriginal Cana-dians 2013. (Accessed May 17, 2015).

4. Khan S, Henry DA, Gershon AS. Chronic airways disease in FirstNations, Inuit and Metis in Canada. Can Respir J 2012;19(6):353–4.doi: 10.1155/2012/590658.

5. Ospina MB, Voaklander DC, Stickland MK, et al. Prevalence ofasthma and chronic obstructive pulmonary disease in Aboriginal and


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non-Aboriginal populations: A systematic review and meta-analysis ofepidemiological studies. Can Respir J 2012;19(6):355–60. doi: 10.1155/2012/825107.

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7. King M. Scaling up the knowledge to achieve Aboriginal wellness. Can JPsychiatry 2011;56(2):73–4.

8. Allan B, Smylie J. First Peoples, Second Class Treatment: The Role ofRacism in the Health and Well-being of Indigenous Peoples in Canada.Toronto, Ontario: Wellesley Institute; 2015. .

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RESEARCH ARTICLE

High-flow nasal cannula therapy for patients withblunt thoracic injury: A retrospective study

Meghan E Halub MD1, Sarah K Spilman MA2, Kristina A Gaunt MD1, Keith D Lamb RRT-ACCS FCCM3,Julie A Jackson RRT-ACCS3, Trevor W Oetting RRT3, Sheryl M Sahr MD MS1,2

High-flow nasal cannula therapy for patients with blunt thoracic injury: A retrospective study. Can J Respir Ther 2016;52(4):110–113

OBJECTIVE: High-flow nasal cannula (HFNC) has been shown to reduce the need for mechanical ventilation (MV) and to decrease hospital and ICU daysfor patients with severe respiratory compromise. HFNC has not been evaluated in trauma patients, thus the goal of this study is to describe the use of HFNCin a chest-injured population.METHODS: A retrospective study examined trauma patients with moderate to severe thoracic injury admitted to the ICU at a tertiary hospital betweenMarch 2012 and August 2015. HFNC was delivered by the Fisher & Paykel Optiflow system. Primary outcomes were the need for intubation afterHFNC for respiratory failure, length of hospitalization, and mortality.RESULTS: During the study period, 105 patients with blunt chest trauma were admitted to the ICU and received HFNC therapy. Eighteen percent receivedMV prior to HFNC. Overall, 69% of patients who received HFNC never received MV, and 92% of patients were discharged alive. The intubation rate forrespiratory failure after HFNC was 18%. For patients who did not receive MV prior to HFNC, delay to first HFNC was correlated with increased hospitaldays (rs = 0.41, p = 0.001) and ICU days (rs = 0.41, p < 0.001).CONCLUSIONS: Study results suggest that HFNC is comparable with other methods of noninvasive ventilation and may be beneficial for patients withthoracic injury. Additional investigation is warranted to determine if early use of HFNC can deliver effective respiratory support and prevent intubation inthis population.

Key Words: high-flow nasal cannula; respiratory failure; mechanical ventilation; blunt chest trauma; Optiflow

INTRODUCTIONHumidified, high-flow nasal cannula (HFNC) is a technique of respiratorysupport that allows for oxygen to be heated to body temperature, saturatedwith water, and delivered at high flow rates [1–14]. Many benefits havebeen noted in post-surgical adult populations and patients with severe respira-tory compromise, including improved mucociliary clearance, better ventila-tion–perfusion ratios, increased oxygenation, reduced work of breathingand inspiratory effort, increased end-expiratory lung volume, and loweredrespiratory and heart rates [1–3, 5, 9–13, 15–18]. Notably, HFNC has theadditional benefit of increased patient comfort and reduced mucosal injury[2, 9, 11–14, 17, 19–20]. Unlike non-invasive ventilation (NIV), it does notimpede mobility, oral intake, or speaking [21, 22].

HFNC studies have also found that the therapy can decrease hospitaland intensive care unit (ICU) days and prevent the need for invasivemechanical ventilation (MV) [11, 19, 23–25]. The efficacy of HFNC therapyhas been established in post-surgical adult populations and patients withsevere respiratory compromise [10, 11, 15, 16, 23, 25], but there areno studies that examine the safety and efficacy of HFNC in a populationcomprised solely of blunt chest-trauma patients. In the only knownHFNC study to include trauma patients, delay to first use of HFNCwas associated with increased ICU days and post-ICU days in a mixedmedical and trauma population, even after controlling for MV andunplanned intubation [23]. It is possible that many of the HFNC benefitsdemonstrated in other clinical populations may be present in the traumapopulation, but this has not been evaluated. The purpose of this retrospec-tive study is to describe the use of HFNC in a population of patientswith blunt thoracic injury to examine if HFNC was associated with positivepatient outcomes such as reduced rates of intubation and decreasedhospital days.

METHODSStudy designA retrospective study was conducted at a tertiary hospital with a mixedmedical and surgical adult ICU. The hospital is verified by the AmericanCollege of Surgeons as a Level I Adult Trauma Center. The trauma reg-istry was used to identify patients with moderate to severe blunt thoracicinjury (Abbreviated Injury Scale (AIS) chest score ≥3) admitted to theICU between March 2012 and August 2015 (n = 358), and 105 patients(29%) received HFNC during their stay. At the time of the study, HFNCwas not specified in a respiratory protocol; the decision to initiate HFNCwas made at the discretion of the trauma surgeon and respiratory therapistwhen supplemental oxygen delivery was required. HFNC was delivered bythe Optiflow system (Fisher & Paykel Healthcare, Auckland, New Zealand).At the study hospital, initial settings are routinely set at 50 L/min and50% FIO2, and the device is titrated by respiratory therapists.

Chart review of the electronic medical record was conducted for datanot included in the trauma registry, and inter-rater reliability was assessedfor 10% of the records to ensure consistency in data abstraction. Thestudy was approved by the institutional review board at the hospital.The requirement of patient consent was waived because chart reviewoccurred retrospectively after patient discharge. No funding or supportwas received from the manufacturer to conduct this study.

Study variablesDemographic and injury variables included patient sex, age, body massindex (BMI), and mechanism of injury. Patients were considered do-not-resuscitate (DNR) if they had a DNR or a do-not-intubate (DNI)order at any time during the hospital stay. Admitting diagnoses wereabstracted from ICD-9-CM codes in the trauma registry for the followingthoracic injuries: three or more rib fractures (807.0–807.2), flail chest

1General Surgery Residency Program, UnityPoint Health, Des Moines, Iowa, 50309, USA; 2Department of Trauma Services, UnityPoint Health, Des Moines,Iowa, 50309, USA; 3Department of Respiratory Therapy, UnityPoint Health, Des Moines, Iowa, 50309, USA

Correspondence: Sarah K Spilman, Trauma Services, UnityPoint Health, Iowa Methodist Medical Center, 1200 Pleasant St, Des Moines, IA 50309,Tel: 515-241-6332, Fax: 515-241-4605, e-mail [email protected]




(807.4), pneumothorax (860.0–860.1), hemothorax (860.2–860.3), pneu-mohemothorax (860.4–860.5), and pulmonary contusion (861.2, 861.3).Acuity was represented by the Injury Severity Score (ISS), which is ananatomical coding system ranging from 0 (no injury) to 75 (most severe).ISS is derived from the AIS, with all diagnoses coded to AIS-1998 values.Comorbidities included smoking history (current or former), ChronicObstructive Pulmonary Disease, and asthma. Delay to HFNC is thelength of time between ICU admission and initiation of HFNC, pre-sented in days to assist in interpretation. Duration of initial HFNC ther-apy is presented in hours.

Patient outcomes included hospital days, ICU days, and post-ICUdays. Discharge disposition was reported for patients without mortalityand included home (with or without home health services) or facility(skilled nursing or inpatient rehabilitation). Finally, it is consistentwith the literature to define HFNC failure as the need for invasive MV(intubation) after HFNC for respiratory failure [6, 19, 24]. If a subjectreceived MV after HFNC, arterial blood gas (ABG) analysis values(pH level, PO2, PCO2, bicarbonate (HCO3), and arterial oxygen saturation(SaO2)) were abstracted from the period 24 h prior to intubation to deter-mine the type of respiratory failure. In cases where an ABG was not drawnprior to intubation due to rapid clinical deterioration, we used the physi-cian bedside assessment of reason for intubation. Subjects were categorizedas having hypoxemic respiratory failure if PO2 < 60 mmHg or hypercarbicrespiratory failure with or without hypoxemia if PCO2 ≥ 50 mmHg [26].If a patient was intubated for a change in mental status or an operativeprocedure and did not have hypoxemic or hypercarbic respiratory failure,the patient was excluded from the HFNC failure rate.

Statistical proceduresAnalyses were performed with IBM SPSS Basic Statistics for Windows,version 20.0 (IBM Corp, Armonk, New York, 2011). Categorical dataare reported as counts and percentages. Distributions of continuousdata were examined using the Komogorov–Smirnov test; because somevariables were not normally distributed, all continuous data are reportedas medians and interquartile ranges (IQR). Correlations were computed

as Spearman rho (rs) or Biserial (rb) coefficients. All statistical tests weretwo-tailed and based on a 0.05 significance level.

RESULTSThe study sample included 105 patients with blunt thoracic injury, anddemographic characteristics of the sample are presented in Table 1.The majority of patients were male (68%), with a median age of 63 years(IQR: 53, 76) and median BMI of 30.5 (IQR: 25.0, 35.4). Patients had amedian ISS of 21, indicating a severe level of injury. Eighty-eight percentof patients had three or more rib fractures, 34% had a pulmonary contu-sion, and 28% sustained a pneumothorax. More than half the patientswere current or former smokers.

Timing and duration of HFNCFigure 1 illustrates the timing of HFNC and MV for all patients in thestudy. Overall, 69% of patients in the study were never intubated. Nine-teen patients (18%) were intubated prior to HFNC; 5 of the 19 patients(26%) who were extubated to HFNC required reintubation for respiratoryfailure. Conversely, 86 patients (82%) did not receive invasive MV priorto HFNC.

On average, HFNC was started 6 h and 40 min after ICU admission(IQR: 0:1:40, 1:00:20), with a median therapy duration of 30 h (IQR:0:14:15, 2:04:19). However, time to HFNC was related to whether thepatient received MV before HFNC. Patients who were not intubatedprior to HFNC started the therapy approximately 3 h after admissionto the ICU, and the average duration of therapy was 30 h. Delay to firstHFNC was associated with increased hospital (rs = 0.41, p = 0.001) andICU days (rs = 0.41, p < 0.001). Patients who were extubated to HFNCstarted therapy 120 h (5 days) after admission to the ICU and averageduration of therapy was 26 h. Neither the delay to HFNC initiationnor the duration of therapy was correlated with any demographics orinjury characteristics in this population.

HFNC outcomesThemedian hospital stay for all patients was 12 days, with a median stay of5 days in the ICU (see Table 2). There was a strong correlation betweenreceiving MV during the ICU stay and hospital (rb = 0.53, p < 0.001)and ICU (rb = 0.56, p < 0.001) days. Eight percent of patients died inthe hospital; none of the deaths were related to use of HFNC and 75%of these patients were DNR or received comfort care. For patients whowere discharged alive, 41% returned home after hospitalization and59% discharged to a skilled-nursing or inpatient rehabilitation facility.

TABLE 1

Demographics and injury characteristics of sample

Demographic or characteristicAll trauma patients

(n = 105)

Male, n (%) 71 (68)

Age in years, median (IQR) 63 (53–76)

Body mass index, median (IQR) 30.5 (25.0–35.4)

Do-not-resuscitate order at any time during

hospital stay, n (%)

17 (16)

Mechanism of injury, n (%)

Motor vehicle collision 54 (51)

Fall 44 (42)

Other 7 (7)

Injuries (not mutually exclusive), n (%)

Rib fractures 92 (88)

Pulmonary contusion 36 (34)

Pneumothorax 29 (28)

Flail chest 10 (10)

Hemothorax 9 (9)

Pneumohemothorax 6 (6)

Injury Severity Score, median (IQR) 21 (14–26)

Comorbidities

Former smoker, n (%) 31 (30)

Current smoker, n (%) 26 (25)

Chronic Obstructive Pulmonary Disease, n (%) 14 (13)

Asthma, n (%) 8 (8)

IQR, interquartile range.

FIGURE 1

Patient flow chart for timing of high-flow nasal cannula(HFNC)

Admit to hospital(n = 105)

Mechanicalventilation priorto HFNC (n=19)

No mechanicalventilation priorto HFNC (n=86)

Reintubated after HFNCfor respiratory failure

(n=5)

Intubated after HFNCfor respiratory failure

(n=14)

Extubated to HFNC,not reintubated forrespiratory failure

(n=14)

Not intubated afterHFNC for respiratory

failure (n=72)


HFNC for thoracic trauma patients

HFNC failure was defined as receiving MV (intubation) after HFNCfor hypoxemic or hypercarbic respiratory failure, and 19 patients (18%)met that criterion. Failure was not statistically related to any patternof injuries but was associated with increased hospital days (rb = 0.40,p = 0.001) and ICU days (rb = 0.54, p < 0.001). In Table 3, we reportthe values from ABG analyses for subjects who were intubated afterHFNC. Nine of 19 subjects (47%) failed HFNC due to hypoxemic respi-ratory failure. Conversely, 12 of 19 subjects (63%) failed HFNC dueto hypercarbic respiratory failure. In the latter group, there was an associ-ated respiratory acidemia (median pH of 7.27; normal: 7.35–7.45), aswell as higher PCO2 and lower PO2 than the hypoxemic subjects.

DISCUSSIONThis is the first known study to describe the use of HFNC therapy in apopulation comprised solely of blunt thoracic injury patients. In thishigh acuity sample of trauma patients with moderate to severe thoracicinjury, more than two-thirds of patients never received invasive MVand 18% were intubated after HFNC for respiratory failure. Outcomesare similar to rates reported in the trauma literature for MV after NIV,which typically range from 12 to 18% [27–29]. Clinical outcomes arecomparable; however, there are also indirect and unmeasured benefitsto patients. HFNC does not impede mobility, oral intake, or speaking,which all improve patient outcomes [21, 22]. The findings suggest thatuse of HFNC may be a suitable respiratory treatment to provide optimaloxygen support to blunt thoracic trauma patients.

HFNC failure has been defined in the literature as the need for MV(intubation) after HFNC therapy [3, 6, 25]. However, we question ifHFNC should be considered ineffective if patients require intubation forhypercarbia. The primary indication for HFNC is hypoxemic respiratoryfailure [13, 19], with a secondary purpose to improve alveolar ventilationby decreasing the work of breathing and flushing the anatomical dead-space, thereby improving hypercarbia [2, 7, 14]. Early HFNC studies didnot support the modality for improving carbon dioxide (CO2) retention[16], but some work supports use of the modality for this purpose [7, 30,

31]. Our results suggest that HFNC may be efficacious in supportingpatients with hypoxemic respiratory failure but less effective for patientswith hypercarbic respiratory failure.

The mortality rate of the sample was 8% and there were no caseswhere HFNC caused harm or delayed definitive care. The literature notesthat blunt chest trauma patients have a mortality rate between 3 and 9%when receiving conventional NIV [26, 27], thus results from the study arewithin this range. It is noteworthy that 16% of patients were DNR/DNIat some point during the hospital stay, and three-quarters of patients whodied were DNR/DNI or received comfort care. HFNC is a potentialmethod of oxygenation for palliative patients because it is more comfort-able and better tolerated than other NIV methods and does not inhibitspeaking or oral intake [21, 22]. HFNC may provide a method of oxygensupport for patients who wish to avoid invasive measures, and furtherexamination is warranted to determine the utility of HFNC in thesephases of care.

Study findings indicate a moderate relationship between delay to firstHFNC and total length of the hospital stay (rs = 0.36, p = 0.001) forpatients who did not receive MV prior to HFNC. It may benefit patientswith thoracic injury to start HFNC immediately after ICU admission, andefforts are in place to make that the standard of care at the study hospital.

An additional reason to start HFNC as early as possible is becausepatient improvement has been found to progress rapidly after HFNC ini-tiation. Sztrymf et al. [25] found that patients with acute respiratory fail-ure noted improvement within 1 h of therapy initiation, and Vargas et al.[32] noted that short-term HFNC use had positive effects on respiratoryeffort and oxygenation. Although patients in these two studies were nottrauma patients, the physiologic effect of HFNC was evident soon afterstarting the therapy and may work similarly in a trauma population.

LimitationsThis is a retrospective study to describe the efficacy of HFNC in a traumapopulation, thus the study has several limitations. First, this study wasperformed at a single trauma center and results may not be generalizableto other settings. In addition, the study is retrospective and does notinclude a comparator group of patients that did not receive HFNC.Because use of HFNC was not part of standard protocol at our hospital,it was difficult to retrospectively identify a comparable patient populationwith equivalent acuity. Future work should be conducted prospectivelyand in collaboration with other hospitals to further evaluate the utilityof HFNC in the chest trauma population. Second, 18 patients in thisstudy received Bilevel Positive Airway Pressure (BiPAP) immediatelybefore or after HFNC, and 6 of these patients oscillated between thetwo therapies (daytime or nighttime). We have not included data onNIV in this manuscript because it was not part of the original studydesign or data abstraction; however, in the future it would be importantto identify the temporal order of NIV and HFNC therapies to determinehow HFNC can best be utilized.

Third, at the time of the study there was no respiratory protocol forthe initiation or titration of HFNC therapy; there may be physicianand therapist biases in which patients were selected to receive HFNCand the settings that were used during therapy. Because there is histori-cally no work on HFNC in a trauma population, this retrospective studyis a first step in directing future research and building protocols suitablefor trauma patients with chest injury.

Finally, HFNC was only available in the ICU at the study hospitaland not on general inpatient floors. Some patients may have avoidedan ICU admission if HFNC was available outside the ICU. Researchersat the study hospital are currently evaluating the feasibility of implement-ing HFNC on general inpatient floors at the institution, which wouldallow more patients to benefit from HFNC therapy without admissionto the ICU.

In conclusion, this retrospective examination is the first to suggest thatHFNC may be considered as an initial respiratory therapy for traumapatients with blunt chest injury. HFNC was well-tolerated and providedadequate oxygen support for patients with moderate to severe blunt chestinjury.

TABLE 3

Arterial blood gas values after high-flow nasal cannula andprior to mechanical ventilation (n = 19)

Hypoxemicrespiratory failure

Hypercarbicrespiratory failure

pH level (median IQR) 7.40 (7.34, 7.43) 7.27 (7.24, 7.31)

PCO2, (median IQR) 37 (36, 48) 57 (53, 65)

PO2, (median IQR) 62 (53, 79) 84 (75, 100)

Bicarbonate (median IQR) 23.6 (20.5, 26.0) 26.4 (22.0, 31.7)

Arterial oxygen saturation

(median IQR)

91.9 (86.14, 94.7) 93.9 (91.0, 97.3)

IQR, interquartile range

TABLE 2

Outcomes of study sample (n = 105)

Outcome All trauma patients

Hospital days, median (IQR) 12 (8–18)

ICU days, median (IQR) 5 (3–11)

Post-ICU days, median (IQR) 5 (3–8)

Mortality, n (%) 8 (8)

High-flow nasal cannula failure, n (%) 19 (18)

Discharge home, n (%)a 40 (41)

Discharged to skilled nursing or rehabilitation

facility, n (%)a57 (59)

aExcludes deceased patients.

IQR, interquartile range; ICU, intensive care unit.


Halub et al.

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HFNC for thoracic trauma patients

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PRACTICE GUIDELINE

Advisory workgroup recommendations on the use ofclinical simulation in respiratory therapy education

Irina Charania RRT BScH CRE1, Karl Weiss BSc RRT2, Andrew J West EdD(c) RRT FCSRT3, Seana Martin RRT4,Manon Ouellet inh DE MEd5, Roger Cook BA BEd MEd RRT FCSRT6

I Charania, K Weiss, AJ West, S Martin, M Ouellet, R Cook. Advisory workgroup recommendations on the use of clinical simulation inrespiratory therapy education. Can J Respir Ther 2016;52(4):114–117

Clinical simulation has become established as a commonly used educational approach in respiratory therapy, though questions remain with regards to theevidence basis for its use in some contexts. In conjunction with the development of a new iteration of the National Competency Framework (NCF), theNational Alliance of Respiratory Therapy Regulatory Bodies (NARTRB) reaffirmed its desire to continue to recognize the use of simulation as an educa-tional tool. Given the expressed uncertainty as to best practices in the use of clinical simulation in entry-to-practice respiratory therapy education programs,the NARTRB requested the creation of an expert workgroup to develop a list of recommendations from which an implementation plan could be developedfor the next iteration of the NCF. The resulting advisory workgroup recommendations are intended to inform the application of simulation in educationprograms relative to the attainment of entry-to-practice competencies as outlined in the current National Competency Profile. The recommendations pre-sented focus on the use of clinical simulation for formative and summative assessment of respiratory therapy competencies. The recommendations indicatethat the use of formative assessment in clinical simulations along with deliberate practice has been clearly shown to improve learning outcomes for whichthe simulations are designed. However, it is advised that the use of clinical simulation for the summative assessment of competency (e.g., to assess readinessfor practice) be exercised cautiously in the context of respiratory therapy education. A number of requisite instructional design factors that should be con-sidered before implementing summative simulation-based assessments are identified, including the validation of summative assessment tools.

Key Words: clinical simulation; assessment; competency; respiratory therapy education

Clinical simulation is not a new phenomenon in the context of respi-ratory therapy education. In past years its role has been graduallyestablished across health professions education, although some suggestthat there has historically been limited research of sufficient quality toprovide robust evidence of its educational utility [1, 2]. In response, anemerging body of research-informed literature is beginning to explicatethe complexities of clinical simulation. For instance, a recent systematicreview by Cook et al. [2] demonstrated that in comparison with no inter-vention, simulation-based health professions education can be associatedwith positive effects on the knowledge, skills, and behaviours of learners.In respiratory therapy in Canada, the knowledge, skills, and behavioursrequired of learners for entry-to-practice into the profession are identi-fied in the current Respiratory Therapy National Competency Profile(NCP). The identification of effective approaches to developing theseentry-to-practice competencies in learners has become a matter of sharedinterest to many stakeholders within the profession.

The Respiratory Therapy NCP was first created in 2003 by theNational Alliance of Respiratory Therapy Regulatory Bodies (NARTRB)and updated after a nationwide professional validation survey in 2011 [3, 4].In this profile the use of clinical simulation was initially introduced withdistinct definitions for high- and low-fidelity simulation. These defini-tions were used when simulation was identified as an acceptable methodof evaluation for 20 of the 315 total competencies listed in the profile [4].This national policy decision was intended to provide some limited flex-ibility to accommodate competency assessment in respiratory therapyprograms that encountered difficulty in ensuring sufficient opportunitiesfor students to gain clinical exposure to those competencies.

The direction provided by the 2011 NCP with regards to clinical-simulation-based student evaluation generated some controversy within

the Canadian respiratory therapy community (e.g., operationalizationof the policy, educational validation of the assessment, etc.). In develop-ment of a new iteration of the NCP—the National Competency Frame-work (NCF)—the NARTRB reaffirmed its desire to continue torecognize the use of simulation as an educational and assessment tool.With expressed uncertainty as to best practices in the use of clinical sim-ulation in entry-to-practice contexts, and in response to action itemsagreed to in collaboration with CoARTE (Council on Accreditation forRespiratory Therapy Education), the NARTRB requested the creationof an expert workgroup to develop a list of recommendations. The work-ing group was asked to examine and define under what conditions simu-lation could be used to assess the entry-to-practice competency ofgraduating respiratory therapy students. The primary mandate of theworkgroup would be to determine how clinical simulation can best beemployed in respiratory therapy education, with the interest of publicsafety and protection at the fore.

In response, the Advisory Workgroup on the Use of Clinical Simula-tion was struck to provide re

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