 Thank you for that introduction. And I'm sorry I couldn't be there with you today. By the time Canada lifted its return travel restrictions, I'd already been assigned to work this weekend. And it's the Canadian long weekend. And I'm sure it's the same there that long weekends are quite hard to trade. So apologies, virtually just gonna have to do in this case, I guess. Before I get started, I have no industry COIs, but I do have my sources of research funding and in kind support listed on the screen there. Now you've seen my objectives on that rolling slide. And I'd like to start with highlighting the changing CICU patient acuity and complexity before diving into staffing models and training. And you know, it's been 55 years since the introduction of the coronary care unit by Killip and Kimball. And 15 years after the introduction of the coronary care unit, this is an article from Dr. Killip kind of reflecting on the initial experience. And I'll give you a moment to read it, but my take on this quote is that it was initially conceived as an arrhythmia monitoring and a response unit. Nothing more and nothing less. It was just timely defibrillation. But over time, people far smarter than me nearly 20 years ago started recognizing that the patient population was drastically changing. But how do we quantify this? Do we have numbers to put this into perspective? And the first analysis was done at a Duke University by my friend, Jason Katz. And it looked at 10 year trends between 96 ending in 2006, which is relevant here. And ending in 2006, patients at the single tertiary center, well, 40% had acute renal failure, 40% were on basal pressers, about a third had invasive mechanical ventilation and 10% had multi-system organ failure, what we would call the historical domain of medical and surgical ICUs. Procedures had changed over that 10 years too. There was decline in swan gans, but a rise in central venous catheterization and prolonged mechanical ventilation. Also the historical domain of medical ICUs. Jake Jensen from Mayo kind of picked this up and noticed the dates. This is another single center analysis picking up in 2007, ending in 2018. And what they found ending in 2018 that about one in four people had shock, one in five had cardiogenic shock, 13% had cardiac arrest and respiratory failure was present in more than a third. Interestingly, the trends are aligned, but multi-system organ failure started at 12% and then rose to over a third by the end of 2018 and acute kidney injury was present in about 40%. Similarly, the Mayo plant described a rise in critical field procedures such as arterial line and central line catheterization in almost 40% and on the right here, you can see that about one in four required intravenous vasoactives. And if you add up non-invasive and invasive mechanical ventilation, they were between 35 and 40% to the population. On top of the acuity, this is an analysis by Sim and my colleagues looking at I think about 300 or sorry, just over 3 million Medicare beneficiaries. And the thing I wanted to point out is that between 2003 and 2013, the comorbidity profile had risen, looking at the number of major comorbidities in excess of three, they rose from about a third to over 50%, thus suggesting that not only is the acuity increasing, but the complexity of the background medical conditions is rising. Well, is this a US phenomenon or does this extend to other countries? And I can say from my own work that we're also seeing this in Canada. And this is a CHI high analysis. This is Canadian Institute of Health Information. And this included about 460,000 different CDI student missions over an 11 year period. Two thirds were to academic and PCI capable centers. And what we found is about 87% at a primary cardiac condition. Right across the middle of the screen, you can see that there's a significant drop over time in stable coronary artery disease. But this was sort of compensated by a rise in non-ST elevation MI and STEMI, cardiogenic shock and heart failure. Similarly, there was a slow but steady rise in procedures, catheterization, mechanical ventilation, dialysis, cardiac arrest. But these overall numbers are sort of belied by the inter-hospital variation. And what you can see here is that some of our CICUs in Canada are very, very sick. And at least one hospital had 100% of patients who require at least one critical care restricted therapy or monitoring, ventilation was as high as 31%, dialysis at 14% and up to a third required cardiac or had cardiac arrest or required active resuscitation while in the units. Fortunately, despite this rising acuity and cakes mix in Canada, regardless of whether they were admitted with a cardiac or non-cardiac condition, it's somewhat reassured to know that our mortality rates have been dropping overall. Now, many of you might sort of say that, well, this is sort of national level data and it includes a lot of community CICUs which really don't represent what you guys do as a major referral center. What is the spectrum of care in tertiary centers? And we've sort of answered that through the cardiac critical care trials network. Initially started as a collection of centers, primarily academic and tertiary in US and Canada and it's since grown to, it's pushing 40 centers that are regularly contributing annual snapshots. And what this shows here on the right is that the primary admitting condition is still MI, but that varies widely between centers as low as 15% to as high as 57%. Cardiogenic shock is the number two condition with atrial arrhythmia is number three. You'll see here that the second largest bar is a smattering of conditions from everything from valve of the heart disease to complex congenital. Well, what is the reason for admission and somewhat surprisingly across the top is that the reason they need the ICU admission is actually not for a cardiac cause, at least directly. You can see here that in over 25%, it's respiratory failure or insufficiency as the primary driver for admission followed by unstable arrhythmias and cardiac shock. Down at the bottom, you see a large proportion of patients are admitted for post-procedural monitoring or frequent labs and tests. And I'm gonna come back to this a little bit later trying to highlight perhaps the overutilization of high acuity care. Well, what is the, or what are the proportion of patients that require critical care-restricted therapies as a rough proxy for appropriateness of admission? And you can see in the middle here that nearly 40% need intravenous vasoactives, about 30% need invasive hemodynamic monitoring. When you add up all respiratory therapies, invasive, non-invasive or high-flow oxygen therapy, it approximates about one in three patients require something of a respiratory nature. A whopping 40% require nothing at all. And that varies widely between institutions. You can see here that the proportion of patients that require no critical care, advanced critical therapies between sites and tertiary centers range from 14 to 62%. We're not perfect at the University of Alberta. We're somewhere here in the middle. I can't remember for GRH, but definitely some room to improve. Now, you're gonna ask me, I'm showing all this variation data and I haven't dug into it yet. Well, the reason I'm showing this data is twofold. One is it allows people listening to benchmark if they have their data, what their own institutional practices are. And number two, I'm gonna set the stage for my fourth objective to try and sort of highlight what this institutional variation means and what opportunities we have to improve and improve admission practices. So I promise I'm gonna come back to this variation issue a little bit later. What about cardiogenic shock? What does it look like in the CIC? Well, two thirds of patients still are that are admitted with shock, still are primary cardiogenic. But what is more surprisingly is that one in five patients with shock are actually mixed shock and 10% are actually hypovolemic and distributive shock which sort of highlights the need for advanced competencies in non-cardiogenic shock conditions. The other surprising thing here is that it's not acute MIs that are formed the most of the cardiogenic shocks in our units. It's ischemic and non-ischemic heart failure that are forming about 50% of all cases. And not surprisingly, you can see here that those with mixed shock conditions have higher points to estimates for in-hospital mortality. Well, is there a variation in the way we practice with cardiogenic shock? And the short answer is yes. The proportion of patients receiving advanced mechanical or temporary mechanical circulatory support ranges from 17 to 50%, probably highlighting the lack of a good RCT evidence. You can also see here that in red, the proportion of all shock patients receiving mechanical circulatory support here is advanced circulatory support, meaning non-IVP. And this varies significantly between centers highlighting the need for research. Well, you'd probably say, well, all these centers are a little bit different. Maybe the Mayo, Planck or Brigham or whatever the center, they just have separate patients and maybe they need more advanced circulatory support. But that's actually not the case. This is a somewhat complex graph that I want to walk you through. We divided all the centers into low, medium and high MCS utilization and then further subdivided them by IVP shock two scores, low, medium and high. And when you look across the centers, the proportion of low and high risk shock is relatively stable between the low and the high utilization centers, thus suggesting that the utilization of more advanced mechanical circulatory support is not driven by patient level differences, rather by institutional practice patterns. What about respiratory failure and mechanical ventilation? Well, you can see here that amongst all C.I.C. admissions in the C3TN about one in three received some form of advanced respiratory therapy and that the biggest utilizers are cardiogenic shock, general medical problems and acute heart failure. But this varies significantly between hospitals between 15 and 56%. And I don't mind saying that in our own hospital, we kind of vary with just mechanical ventilation. If we're between 17 and 21%, I don't have the data for high flow or noninvasive available, but we're somewhere in the middle of this group. And it's not surprising to see here that if you have respiratory failure and an additional cardiac complications that the rate of death is very, very high. When a second organ fails after the heart, it's an independent respect for mortality. And that's probably not a surprise to anyone. What about advanced renal replacement therapy or acute renal replacement therapy in the C.I.C.U? Well, on the left here, you can see that the biggest or the most common conditions requiring renal replacement therapy are MI, cardiac shock and heart failure. It's used somewhat infrequently, 6% of the overall C.I.C.U population in tertiary centers, but a huge inter-hospital range as low as 1% to as high as 16%. And it's probably not surprising that if your kidneys are failing, you have a lot of other C.I.C.U restricted therapies, including intravenous drips, mechanical ventilation or mechanical circulatory support. And when the kidneys fail on top of the heart, you have overall the median in hospital mortality rate is about 42%. Again, probably not surprising when you have more than one organ failing in hospital. But this really high mortality rate really suggests the need for risk prediction scores to help identify utility versus potential benefit of C.I.R.R.T. in this high-risk population. So the end of my first section, I'm posing the question, have we evolved into a medical ICU? And my short answer is no, but there is a growing overlap in diagnoses, such as ischemic heart disease, diabetes, obesity, hypertension, CKD, others, sorry, that is comorbidities. The diagnoses, including respiratory failure and ischemic heart disease are overlapping. When you have critical care restricted therapies, there's going to be overlap in complications, such as ventilator acquired pneumonia or central line infections. And we do have overlap in critical care therapies, such as mechanical ventilation, dialysis and vasoactive meds, but the C.I.R.R.T. is still different. We don't see a whole lot, at least in Canada, of swan gans catheters, transgenus pacing or mechanical circulatory support in our medical ICU's. And this has implications for staffing and training, which I'm going to highlight a little bit later. So for my second objective, what is the evidence to support new staffing models? And I want to go back 20 years to the Pranavost meta-analysis in ICU's that compared to open versus closed staffing units. And they defined here closed units or high intensity units as either closed units staffed only by intensivist or mandatory intensive care consultation. And what you can see here is that there was a 40% decrease in hospital mortality in a closed unit. And these are medical and surgical ICU's and a few pediatric units. But what is the evidence in C.I.R.R.T. use? And the evidence is emerging, but it is there. And this is a before and after study from the University of North Carolina when they went from an open model with multiple unit attendings to a single unit attending in a closed model. And point estimates for mortality decreased, albeit non-significantly, but what they did find is that there was a one day decrease in median length of stay. What they also found here is despite an increase in the case that makes mixed index as shown by this line here is a proxy for complexity that overall costs in the C.I.R.T. on a per-patient basis went down in the closed model. What about mortality? And this is Elliott Miller's analysis from Yale and they closed their C.I.R.T.C. in 2017. And you can see here prior to 2017, it was a pulporea of attendings university and private group base attending in a 14 bed unit. And they transitioned to a closed unit with a heart failure team or an I.C. team. And what you can see here is that after they closed the unit after multivariable adjustment, there was a significant decrease in in-hospital mortality and C.I.C. mortality. And looking at specific conditions, this was largely driven by people emitted with cardiac arrest or respiratory failure, albeit point estimates for even things like the compensated heart failure did improve, albeit the confidence intervals didn't cross, I still crossed one. What is surprising despite this data, this is a survey from 2017 of action get with the guidelines and mission lifeline hospitals with about 517 responses is that at least five years ago that three out of four C.I.C.Us in the U.S. were made open. And academic or tertiary units were a little bit better, albeit not perfect, that 60% of the units were still open. So here's a huge opportunity for improvement across the United States in terms of improving the staffing model and potentially improving patient care outcomes. Compared to the U.S., this is surprising to us that in Canada were not perfect, but at least in a survey six years ago, we found that three out of our four units in academic centers were closed. Well, we can talk about the staffing models, but what about the levels of care? And one of the principles we put forward is getting the highest acuity patients to the centers that can comprehensively centralize their care from suscitation through to recovery or destination therapy. And the rationale behind these systems of care is that clinical volumes are tied to patient outcomes. This is a meta-analysis of 10 PCI studies, 1.3 million patients. It's not going to surprise NAVU that high-volume PCI improves outcomes. Same in surgery, this is seven per 1.4 million patients undergoing cabbage, high-volume cabbage centers have better outcomes. Well, this extends to non-procedural care too. And if we look from this Medicare analysis of 3.4 million people, we can certainly find thresholds for MI at about 610, thresholds for heart failure at 500 and pneumonia at about 210, thus suggesting that it's not just the procedure, it's the volume of medical care that is associated with outcomes as well. And in the CICU, I'm sure many of you are aware of the outcomes that cardiogenic shock volumes are associated outcomes, but more recent data led by one of my fellows show that in mechanical ventilation volumes in the CICU matters well, and this is another pan-Canadian analysis of nearly 50,000 patients undergoing mechanical ventilation, nine out of 10 of them were invasive and the other 10% were non-invasive mechanical ventilation. And what you can see here with the averaging line is that at about 100 patients or more, you start to get an improvement in all-cause survival to the hospital discharge or you saved another way, a reduction in in-hospital mortality, then again, plateaus at about 300. This needs to be validated obviously, but it does suggest that mechanical ventilation volumes on an institution levels may be a potential benchmark for CICU quality. So in this cartoon, what I'm trying to show you is that it doesn't really matter if you call yourself tertiary or your academic. In some sense, the volumes you put through and the number of patients you see with a number of conditions are tied to patient or tied to better patient outcomes. And these volumes can also be addressed by improving the systems of care that saved lives. And I'm sure many of you are aware that systems of care have been successfully implemented for many times sensitive high-acuity conditions such as STEMI, stroke, trauma, dissection out of hospital cardiac arrest. And dare I say that cardiovascular care is not the leader. The grandfather of systems of care was probably trauma. And this data here shows from 14 states including 18 level one trauma centers and 51 non-trauma centers. It shows that if you were admitted to a hospital for trauma at a level one center, your relative risk of mortality was 20% lower if you went to a level one trauma center than somewhere else. Thus suggesting centralizing the care of these high-acuity conditions improves outcomes. Well, what about cardiovascular care? And this is from the STEMI accelerator program. And this is 12 metropolitan US regions, 12 PCI hospitals and just under a thousand EMS centers. And two things were going on here. One was the quality feedback cycle, but there was also a systems of care for revascularization in these metropolitan centers. And when you participated in this STEMI accelerator program your first medical contact device time less than 90 minutes significantly improved. And if you are part of the accelerator program here the there was a reduction in mortality that was not seen if you were not participating in these systems of care and regional care models. Dare I say that it's really not STEMI, it's not even cardiogenic shock that is the highest risk condition that we see on a regular basis. It's probably cardiac arrest or out of hospital cardiac arrest. And this is just as my opinion, this is from the Institute of Medicine that OCA survival hospital discharge in all comers is estimated to be less than 6%. But this does include the people that are pronounced in the field or pronounced in the ED. We see a very select number of patients that survived the hospital discharge and they undergo targeted temperature management and other ICU level therapies. Well, do systems of care save lives? And I think the answer is yes. And this is an analysis out of Arizona by Dan Spate and Ben Bogrow. And what they did is they took the entire state of Arizona and they designated 51 cardiac arrest receiving centers. And these centers could centralize care from everything from resuscitation to PCI through to ICD implantation and facilitate neuro rehabilitation. And the plan was to transport these patients directly to these centers. And in the after implementation phase, you can see here that amongst all rhythm witnessed arrest and shockable rhythms that survival to hospital discharge and positive neurologic outcome survival improved after implementation of these region care models. What's buried in the text here that doesn't often get talked about is that I believe they implemented hospital bypass of community centers directly to level one centers. Thus, dispelling the myth that there's something potentially life-saving about pulling an ambulance over to a community ICU to have a community ER doc continue a code. The idea here is like trauma is to get them to a level one center as quickly as possible and at least in all comers that saves lives. Okay, so I've said that we need to get higher acuity conditions like shock and STEMI and cardiac arrest and mechanical ventilation to tertiary quaternary centers, but this is gonna result in a significant higher level of acuity. And what are the strategies to embrace this new acuity and technology safely? And there's a few possible suggestions out there in the literature. And the first is staffing with CICU Intensivist. And this is a study out of Korea published in Jack. And what they were able to do is transition from an open model with multiple non-CICU Intensivist trained intending to a closed model where everyone was dual trained in cardiology and critical care. And what you can see here is that CICU mortality dropped from nearly 8% to 4%. What is more surprising to me is that this wasn't just a decrease in non-cardiovascular death and sepsis, which you might expect with some people with ICU level training is that there was a significant decline in cardiovascular death as well. But you're gonna say, well, there's no large pool of critical care cardiologists to fundamentally change our staff and overnight. What are other care models? And this is from the University of Maryland where they had no intensive care cardiologists to my knowledge. And what they implemented is mandatory consultation in patients undergoing invasive mechanical ventilation. And what you can see here in that the post intensive care consult period is there was a significant reduction in CICU length this day and an increase in ventilator three days. And when they looked at adjusted mortality, there was also significant reduction in odds of survival or reduction in the odds of mortality when adjusted for Apache too. So this suggests that there may be a role for team-based care. If you're on the unit as an attending one week, it's not just you, but care and outcomes maybe improve when you work with a group of people including intensivist, internal medicine, sub-specialty surgeons and allied health professionals. And this concept of team-based care has certainly played out in the cardiogenic shock literature. And this is the cardiogenic shock algorithm from ANOVA where they had activation of a shock team if you had low blood pressure with endocrine hyper-profusion and through single point of care access call, it activated IC, cardiac surgery, advanced heart failure and cardiac critical care. And in the post-implementation period, you can see that there's a near doubling in survival for acute MI shock and a 12% increase in survival for acute decompensated heart failure related shock. Now you might ask me, you know, this is observational. Is it biased potentially? Could it be confounded? Probably, but do I believe it? Absolutely. And why do I say that is that I believe it because through all of medicine, the earlier intervention in high acuity time-sensitive conditions improves outcomes. I can also say that with a little bit of confidence in that the University of Ottawa and the University of Utah have shown similar analyses with the implementation of their shock teams that showed improved survival. Now you may say these are single center and maybe there's some temporal trend biases. Is there any multicenter data? And there is this year. And this is from the CT3TN and this is a cross-sectional analysis of 24 CICUs in US and Canada, only 10 of which had a shock team. And in the centers that had a shock team, what you can see here is that there is a higher use of pulmonary arterial catheter and overall lower use of mechanical circulatory support, which somewhat paradoxically is offset by a higher use of more advanced mechanical circulatory support. But in the shock team centers, there was a 3% absolute reduction in CIC mortality, thus suggesting building a picture that team-based care is associated with better outcomes. So I'm putting this slide up, not to make fun of patients, but rather to make fun of us as physicians. And sometimes it's easier to change physician practice by adding a new medication or to the armamentarium or change surgical practice, but it's harder to change the way we deliver care. And the data thus far goes that perhaps there's some potential improvements we can make to CICU staff in practice. Number one, by closing units with unit-based attendings. Number two, centralizing the care of high acuity conditions to hub centers that can comprehensively centralize their care from resuscitation through either palliation or recovery. The dual training of CICU attendings in critical care and the adoption of team-based care for non-critical care attendings or even conditions such as cardiogenic shock. All right, so what are the pathways for trainees to get advanced training in critical care? And I'm putting this first slide up, which is from our Canadian CICU paper because as I've given similar elections in person, I've been accosted afterwards by a few very spirited attendings thinking I'm trying to push competent people out of the CICU and that's not the case. I'm putting this up because I wrote this paragraph and I think that current CICU physicians that are experienced, committed and maintain an adequate volume of practice and competency shouldn't be pushed out. We need these people to deliver care, although care may change and training may change in the future. We need people who have practice in CICU because we can't replace them with people like myself and at least data from a survey five years ago showed that only 15% of centers actually have a critical care cardiology training program and a similar percentage of centers had at least one CICU intensivist and that's one, that's not multiple. So we really can't replace all these people and we're not much better in Canada. This data is a little bit older from a survey at the end of 2014, but then we've only had two people or two centers with a cardiac intensivist and there's my response. I'm fortunate to say that we're graduating many people a year in these programs, but we're nowhere near ready to change over stacking practices in our major centers. So what are the pathways to training? And in 2012, Dave Morrill with the scientific statement had proposed an additional completion of 12 months of clinical fellowship in critical care medicine to get expertise in things like airway management, ventilation, CRRT, and that they proposed two potential pathways. One is you finish your ICU or sorry, you finish your critical care and do a year in ICU, but also the development of integrated programs like four year programs at least where you do critical care training currently with your ICU. And there has been some advancement, albeit not perfect within the U.S. I don't pretend to be the U.S. expert, but what I can say is that the AIBM mandates at least 12 months of critical care exposure before you can write an exam and COCATS-4 has come through with some training guidance. They don't have a nice figure, but in essence they have level one, two and three training standards and level three would require an additional 12 months or one year in critical care medicine to work in primarily high volume academic centers. There are some challenges though with these recommendations is that there are still a small number of training programs in the U.S. and throughout Canada. The training is sometimes done through dedicated critical care medicine programs, although there are some standalone CISU programs and there's an inconsistent patchwork of examination of certification criteria. To my knowledge in the U.S., there aren't any concurrent programs where you can roll in cardiology right at the beginning and graduate with dual certification. In Canada, we're a little bit different. You may not realize that critical care medicine is actually a two year standalone fellowship, which I did, although two of our centers, including the University of Alberta have one year programs designed to allow people to practice only in CISU. This would exclude them unlike the two year program from practicing in medical, surgical and neural ICUs. The European Union through the ESCE is miles ahead of both our countries. They've now had two documents on what they call ICCU, intensive cardiac care units that have proposed staffing and structure. And they've been pretty clear through the acute cardiovascular care committee and that they have clearly defined ICCU levels one to three. They have multiple established one year training programs with formal examination and accreditation criteria that is recognized throughout the EU. And they also have a dedicated congress and journal which we're also trying to improve on in North America as well through the ACC and the ACCHI. So my last objective is to try and summarize the evidence to support moving away from historical admission practices such as everyone within MI or positive troponin or CKMB got admitted to a CISU. I think that has changed. And this is from the U.S. premier registry of 306 hospitals and it was published by Harlan Krumholz's group. And what you can see here is that in these 306 hospitals the median CISU admission rate for people within MI was about 40% but there was almost an unfathomably large inter-hospital variation rate from zero to 98%. What they found is that in the highest admission cortex so that is hospitals admitted the most patients. The highest emitters had the lowest proportion of patients with critical care restricted therapies that included pa-catheter use, vasoactives and mechanical ventilation. And when they looked at this, when they looked at by a risk standardized mortality rate here on the Y versus ICU admission rate on the X axis the scatter plot shows that that you can imagine an almost perfectly flat line through the scatter plot suggesting that there's no association between ICU admission rate and overall outcomes in these hospitals. They did a similar analysis the same group from the U.S. Premier Registry with heart failure and this was published in circulation. Although the median admission rate for heart failure was between 10 and 12%, there was a similarly large inter-hospital ICU admission rate that ranged between 0% and 88%. Again, they found the same relationship. High ICU utilization centers had the lowest use of critical care restricted therapies such as vasoactives and mechanical ventilation. And again, when they looked at risk standardized mortality rates, the high and the low admission groups, there was absolutely no difference. Now, I don't want you to feel like I'm picking on cardiology. This is a problem that extends to ICUs as well. This is a four state analysis of medical ICUs and they took four common medical ICU admission conditions DKA, PE, upper GI bleed and congestive heart failure. And again, a similar scatter plot that looked at adjusted mortality versus probability of ICU admission. And again, through all these conditions, you can see almost perfectly black correlation curve thus suggesting that ICU admission rates don't correlate with survival. Now, is this is an American model? Is it just you guys? Surely this can't be happening in Canada where we have single-payer healthcare systems and we're not for profit. Well, that's really not the case. We're not much better than you guys. And this is dated from my own analysis. And what you can see is our Canadian provinces across the bottom here. And in blue, we have STEMI, yellow and STEMI, unstable angina in gray and heart failure in red. And to sum up this variation, which you can see visually, the inter-provincial differences in STEMI admission rates vary by 35%. And STEMI, it's even worse. The variation is almost 60%. Unstable angina 30% and heart failure by 50%. And when we look at provinces by the percentage, this is a heat map of the percentage of patients who do not get any critical care therapies within two days of admission. What you can see here is we're not doing very well. We have some provinces where 80% of patients don't get any critical care therapy. And even at best in British Columbia, 46% of patients don't get critical care therapies, thus suggesting that patient acuity and hospital care resources aren't aligned and there's an opportunity for improvement. We did a similar scatterplot here on a provincial basis looking at ICU admission rate versus adjusted mortality. And you know what? Don't get fooled by, whoops, by a p-value of 001. And R squared of nine really suggests that the only 9% of the inter-provincial differences in mortality can be explained by admission rates stated another way. 91% of the inter-provincial differences in mortality are explained by something else, meaning that this is a very small contributor to differences in outcome. In Canada, we also looked at hospital size and the volume and the size of our hospital really matters when we look at these inter-provincial differences. What you can see here on the left is that our teaching hospitals had the highest proportion of patients in the CIC with critical care restricted therapies. And if you look at patients here, obviously this is the same data presented a different way. And a minority of those had none within the first two days. So that meaning that some did compensate over time. Our small community hospitals were the biggest defenders where only 9% of the patients had any critical care restricted therapies. Thus suggesting that there's a potential to better align practices. What about specific conditions? And do end-stemmies really benefit from routine CIC admission? Well, guidelines say that stable end-stemming patients can go to a telemetry ward based on level C evidence. And one of my own analysis looked at this, this is an editorial by Dave Morro's trainee. And what I'd like you to pay attention to are three things. The year of many of these data were all pre-2003 until recently, my own analysis was 2008. And many of these studies were just several hundred people with mortality rates of exceeding 10%. The analysis I'm going to show you, we dwarfed all of these by analyzing 8,000 patients and had a more contemporary CIC mortality and ward rate of 1.2 and 1.3% respectively. The way we were able to do this was through data linkages. We have population health data sets that we're able to link. And I think we're able to quite clearly compare patients who were stable at the time of admission. And we looked at those admitted to a CCU versus a cardiology ward with telemetry capabilities. And as I've sort of foreshadowed here, there was no difference in in-hospital death shown above here. And that was the same between low intermediate and high risk patients. We also looked at these patients between end-stemming and unstable angina. No difference. We looked at those that were cared for by primary cardiologists, no difference. We even sub-selected the people that underwent an in-hospital angiogram and then further risk stratified them by Duke-Jeopardy score, angiography score. Again, no difference, suggesting that there's nothing life-saving about a CIC admission for an end-stemmy patient. Really what they need is a telemetry monitor if they don't require the provision of critical care-restricted therapies. Well, there's some costs to this too. ICUs are expensive care units. And in my own work, what we've tried to do at least in Canada was evaluate the potential cost savings. And in looking at all Canadian CICU admissions for non-ST elevation myocardial infarction, we looked at those in high, medium, and low utilization centers. And not surprisingly that the low utilization centers had the lowest proportion of in-hospital costs incurred by CICU care. What we found is that there was no difference in mortality by utilization. And we also posed the question, well, what if all hospitals adopted low utilization patterns? And we were really conservative in what this meant. And we estimated that the savings would be $113 million. If we were less conservative, that was about three and a half times fire. Using back of a napkin calculations, your population in the US, you're about 10 times bigger and your hospital care is, I don't know, about 30% more expensive. So suddenly in the US using these metrics, if it were to hold true, the cost savings in the US would be 10 figures. Well, heart failure might even be a bigger problem. In Canada, we had inter-hospital admission rates to CICUs ranging from 0% to just over 50%. And a similar graph shown a different way is that in our high utilization hospitals for CICUs and heart failure, they had the highest proportion of hospital costs incurred by CICU. But also in blue here, the lowest proportion had the lowest proportion of critical care therapies same to the crumpled papers. And when we looked at the potential cost savings, it was $234 million. And you can do the back of the napkin calculations on what that might mean in the US. Well, what about STEMI? Like do all STEMI still require an admission to CICU? And I'm gonna argue no. People have maybe forgotten the Zoli score, which is applied post primary PCI and includes six metrics. And in the validation cohort for the Zoli score, if you have a Zoli score of four or less, you have a less than 1.5% chance of 30-day mortality. Thus suggesting that you have a really low risk and maybe you could go to a telemetry-enabled ward. And my friends and colleagues in Winnipeg actually tested this prospectively. And in 450 patients, they used the Zoli score to stratify them into low and high-risk patients. And not surprisingly, amongst the low risk, there were some appropriate clinically-driven crossover for things like ASA desensitization or bradycardia that are uncapped by the score. But what you can see here is that amongst the low-risk patients that went to a ward, the in-hospital mortality rate was 0.5%. And when you compare the low-risk patients that went to either telemetry ward or CICU, somewhat reassuringly, there was no difference in things like cardiogenic shock, pulmonary edema, renal replacement, or in-hospital death. And the Zoli score performed pretty well. I mean, the C-index here was 0.91, which is excellent as far as models go. Thus suggesting that your low-risk STEMI patients post-primary PCI can safely be discharged to the ward. And this is something we try and do at our own institution because we just don't have the critical care capacity to deal with all the STEMIs. So with this cartoon, the argument I'm trying to make here is that I think we have a misalignment between expensive high-acuity and high-acuity CICU resources and patient care needs. And there's a substantial population of the patients we care for in the US, Canada, and abroad that can potentially be cared for in a lower-acuity environment. And I'm putting this cartoon up not to make fun of patients, but to tease us as ICU attendings. Well, maybe it shouldn't just be up to the ICU attending in all cases, whether they need urgent level of care or lower-acuity care. And this is something that we've tried to propose in a thought piece and circulation. And that maybe CICU admissions may warrant appropriate use criteria in the future. And I won't go through all these columns, but the principle is threefold. Number one, are the patient's goals of care and the potential benefits in keeping with CICU? Number two, do they need critical care restricted therapies like mechanical ventilation or vasoactics? If they do, they should be admitted if their goals care a lot. And finally, if you don't require critical care restricted therapies, what is the meaningful risk of clinical deterioration? And I think when you look across many common admission criteria, we can find stratum of these patients that could be better cared for in a lower-cost telemetry environment, like a ward or even a step-down unit, depending on the infrastructure of your hospital. So to summarize the CICU utilization, I think the clinical acuity and complexity of CICU patients has increased, but there's significant inter-hospital variation. Dual training and cardiology intensive care is growing, but we need experienced and competent cardiologists to continue to provide the care. But team-based care is growing and is evolving into a practice standard into things like cardiogenic shock. Our CICU admission rates and the provision of CICU restricted therapies is variable and observational studies that many end-stemmies and low-risk stemmies can be cared for in a ward. So this is my last slide put together by a piece of Jack by my friend Jason Katz kind of outlining the evolution and maturation of critical care in cardiology. And I think we've shown in foundations that we have evolving acuity and comorbidity in our units. Care delivery, I think we've shown that we can improve patient outcomes with improvements to staffing, structure, and regional systems of care and the adoption of standard protocols. We're growing in educational and training. We're not there yet. There's still a relatively small number of people like myself that are dual trained, but this is growing. And the final frontier is CICU-based research showing that there are practice standards with treatment standards that can improve care in things like cardiogenic shock or very advanced acute to complex heart failure and so on and so forth. So with that, I will end my presentation and I'm happy to take questions. And I appreciate the comment at the beginning about the Battle of Alberta. The first game didn't go very well for us in Edmonton and we're looking for a better result tonight. So thank you for your attention.