Australian ICU Research Articles

Disaster preparedness for intensive care units: Priorities to inform crisis standards of care

BackgroundThe number of disasters occurring globally is increasing. Natural hazards, changing geopolitical situations, and increasing population densities may lead to an increased likelihood of a surge of patients requiring health care, some of whom might be requiring intensive care–level treatment. There is a dearth of literature on intensive care unit (ICU) practitioner's priorities regarding disaster preparedness and crisis standards of care. ObjectivesThis study aimed to understand what nurses working in ICUs within Australia prioritise regarding ICU disaster preparedness and the implementation of crisis standards of care. MethodsA modified three-round Delphi design was used for this study. A snowballing recruitment method facilitated the purposive sampling of ICU nurses, starting with members of the Australian College of Critical Care Nurses. Eligible participants were asked to rate statements according to their priorities when addressing disaster preparedness of the Australian ICU in which they work. Statements that achieved the 10 highest scores in the final round were tabulated to indicate the broader areas of disaster preparedness that the respondents considered priorities. ResultsA total of 16 participants completed both round two and round three of this Delphi study. Out of 38 statements across six domains, 33 statements achieved consensus. Healthcare practitioner protection, wellbeing, and the management of space populated the top 10 priorities. These priorities included adequate personal protection equipment, services to support healthcare practitioners, and clear communication and debriefing pathways. Another key priority identified was the need for a clear plan on how the ICU footprint will expand to accommodate a surge of patients. ConclusionHealthcare practitioner wellbeing followed by adequate plans for ICU expansion are key priorities of nursing staff working in ICUs within Australia. Understanding the priorities of those who work in the ICU gives a pragmatic insight into what is required to further develop the disaster preparedness of Australian ICUs.

Nutrition delivery during hospitalisation after critical illness in Australia and New Zealand: a multicentre, prospective observational study.

Energy and protein provision for critically ill patients who receive oral nutrition often falls below recommended targets. We compared characteristics and nutrition processes during hospital stay (within and post-intensive care unit [ICU] stay) of those who received oral nutrition as the sole nutrition source to those who first commenced enteral (EN) or parenteral nutrition (PN) within an Australian or New Zealand (ANZ) ICU. Multicentre, observational study of routine nutrition care in 44 hospitals across ANZ, including adult patients within ICU admitted for at least 48 h. Those receiving oral nutrition as the sole source of nutrition (with or without oral nutrition supplements) were included in the 'oral nutrition' group and those who first received EN and/or PN in the ICU as the 'EN/PN group'. The primary outcome was median daily energy delivery in ICU. Data are presented as number (%) or median [interquartile range]. Of the 409 patients enroled, median [IQR] age was 64 [51-74] years and 257 patients (62%) were male. APACHE II score, use of invasive ventilation and hospital length of stay (LOS) were all lower in those receiving oral nutrition (n = 200) compared to those receiving EN/PN (n = 209). In ICU, 63 (31.5%) and 169 (81%) (p < 0.001), patients who were receiving oral nutrition and in the EN/PN group received a nutrition assessment, respectively. Oral nutrition supplements were provided for 40 (20%) patients in the oral nutrition group and 31 of 94 (33%) of those receiving oral nutrition in the EN/PN group (p = 0.019). Energy and protein intake in ICU for the oral nutrition group was 716 [597-1069] kcal/day and 37 [19-46] g/day versus 1158 [664-1583] kcal/day and 57 [31-77] g/day for those receiving EN/PN (p = 0.020 energy, p = 0.016 protein). Quantification of oral nutrition was attempted in 78/294 (27%) patients in ICU and completed on 27/78 (36%) occasions. On the ward, attempts were made for 120/273 (44%) patients, with 60/120 (50%) complete. Patients who received oral nutrition as the sole nutrition source in ICU had lower illness severity, rates of nutrition assessment and provision of oral supplements compared to those who first received EN/PN. Quantification of oral nutrition was often incomplete for all patients in ICU and on the ward.

The association between neurocritical care services and patient outcomes in adults with acute brain injury admitted to an Australian ICU between 2016 and 2020

The association between neurocritical care services and patient outcomes in adults with acute brain injury admitted to an Australian ICU between 2016 and 2020

Cefazolin susceptibility of coagulase-negative staphylococci (CoNS) causing late-onset neonatal bacteraemia.

CoNS bacteraemia causes significant neonatal morbidity. Previous work has suggested that β-lactam antibiotics vary in their binding affinity to PBP2a (produced by the mecA gene) present in most CoNS. We evaluated cefazolin MICs for CoNS isolated in an Australian neonatal ICU (NICU) and correlated them with isolate genotype and phenotype. Significant blood isolates from 2009 to 2017 were speciated and underwent broth microdilution testing for cefazolin, cefoxitin, oxacillin and flucloxacillin. Correlation with mecA presence and PBP2a expression was evaluated. A selection of Staphylococcus capitis isolates underwent WGS. The CoNS (n = 99) isolates were confirmed as S. capitis (n = 57), Staphylococcus epidermidis (n = 32), Staphylococcus haemolyticus (n = 2) and Staphylococcus warneri (n = 8). The MIC of cefazolin was ≤2 mg/L for 30% of isolates and 75% had an MIC of ≤8 mg/L (MIC90 = 16 mg/L). This contrasted with MIC90s of cefoxitin, oxacillin and flucloxacillin, which were all ≥32 mg/L. WGS found a number of S. capitis isolates closely related to the globally established NRCS-A clone. CoNS displayed distinctly lower MIC values of cefazolin than of other agents tested. MIC variation may be related to binding affinity of PBP2a or regulation of expression of mecA by mecR1-mecI functional genes. Further, NRCS-A S. capitis strains were present in this Australian NICU before and after the unit underwent physical relocation, which raised questions about a common environmental source. It is considered justified to conduct a randomized clinical trial that assesses cefazolin versus vancomycin for management of late-onset neonatal sepsis.

909: Challenging Informed Consent: A Study of Off-Label Medication Use in an Australian Adult ICU

909: Challenging Informed Consent: A Study of Off-Label Medication Use in an Australian Adult ICU

Doing time in an Australian ICU; the experience and environment from the perspective of patients and family members

BackgroundThe intensive care environment and experiences during admission can negatively impact patient and family outcomes and can complicate recovery both in hospital and after discharge. While their perspectives based on intimate experiences of the environment could help inform design improvements, patients and their families are typically not involved in design processes. Rather than designing the environment around the needs of the patients, emphasis has traditionally been placed on clinical and economic efficiencies. ObjectiveThe main objective was to inform design of an optimised intensive care bedspace by developing an understanding of how patients and their families experience the intensive care environment and its impact on recovery. MethodsA qualitative descriptive study was conducted with data collected in interviews with 17 intensive care patients and seven family members at a large cardiothoracic specialist hospital, analysed using a framework approach. ResultsParticipants described the intensive care as a noisy, bright, confronting and scary environment that prevented sleep and was suboptimal for recovery. Bedspaces were described as small and cluttered, with limited access to natural light or cognitive stimulation. The limited ability to personalise the environment and maintain connections with family and the outside world was considered especially problematic. ConclusionsIntensive care patients described features of the current environment they considered problematic and potentially hindering their recovery. The perspective of patients and their families can be utilised by researchers and developers to improve the design and function of the intensive care environment. This can potentially improve patient outcomes and help deliver more personalised and effective care to this vulnerable patient population and their families.

Feasibility of using the mnutric nutritional risk screening tool to identify nutritionally at-risk patients in an Australian ICU

Introduction: The modified NUTrition Risk In the Critically ill (mNUTRIC) score has been demonstrated to accurately quantify the risk of negative patient outcomes and discriminate which patients will benefit the most from nutrition intervention in the context of critical illness. However, the mNUTRIC is not widely used and questions have been raised about whether this is feasible in the context of routine clinical practice. Objectives/Aims: The purpose of this study was to assess the feasibility of nutrition risk screening using the mNUTRIC tool. Methods: A retrospective observational study of critically-ill patients admitted to the ICU was conducted. All patients admitted to ICU for ≥72h during the 5-month period from 1 January-30 May 2017 were included. Feasibility was determined by time taken to calculate the mNUTRIC score where resources suggested feasibility would be supported if this could be done in <5 minutes. Data availability was also a feasibility outcome with all data to be available for >90% of patients. Results: For the 260 eligible patients, calculation of a mNUTRIC score took a median of 4 minutes and 54 seconds (IQR 4.3-5.6 mins) with 96% of scores calculated in <10 minutes. Data were available to calculate mNUTRIC scores for 93% (241/260) of patients. One-third of the patients (n=81, 31%) were at high nutrition-risk with a mNUTRIC score of 6. Of these, 44% (36/81) had not been reviewed by a dietitian. The feasibility of using the mNUTRIC score in clinical practice was contested given dietitian availability in this clinical setting (0.6FTE). Conclusion: Available staffing resources can impact the feasibility of manually calculating mNUTRIC scores. An approach which adopts a shared responsibility for nutrition screening or automating the calculation may be possible solutions to increase feasibility of using the mNUTRIC score in clinical practice.

Validation of Epworth Richmond's Echocardiography Education Focused Year.

OBJECTIVES: College of Intensive Care Medicine mandatory training in echocardiography requires a minimum 30 echocardiograms. Trainee echocardiography accuracy following mandatory training is unknown. Our objective was to determine the reliability of ICU trainee echocardiography after our yearlong College of Intensive Care Medicine accredited course. DESIGN: Single-center, prospective observational study. Trainee echocardiograms were compared to independent, blindedexpert echocardiograms, with a target of 37 matched scans per trainee. SUBJECTS: Trainees were eligible to participate on completion of our in-house, mandatory echocardiography training. SETTING: Epworth Richmond is in an Australian, private academic hospital with a critical care echocardiography teaching program. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Reliability was assessed on nine measurements. The primary outcome was agreement on left ventricular function; secondary outcomes included qualitative and quantitative assessments. Agreement was assessed using Cohen's kappa, Fleiss-Cohen weighted kappa, Lin's concordance correlation coefficient, or calculation of sensitivity and specificity as appropriate. Seven trainees performed a total of 270 matched scans. There was excellent agreement between experts and trainees for left ventricular function (Kappa, 0.86; 95% CI, 0.81-0.91). Secondary outcome measures (95% CI) were ventricular size ratio Kappa 0.76 (0.58-0.94), sensitivity 92.3% (64.0-99.8%), specificity 97.2% (94.9-99.1%), pericardial effusion Kappa 0.37 (0.13-0.60), sensitivity 33.3% (13.3-59.0%), specificity 97.6% (94.8-99.1%). Concordance coefficients (95% CI) for the remaining outcomes were left ventricular outflow tract velocity time integral 0.79 (0.74-0.84), left ventricular internal diameter in diastole 0.82 (0.78-0.86), left ventricular outflow tract diameter 0.61 (0.53-0.69), tricuspid annular plane systolic excursion 0.71 (0.64-0.78), tricuspid regurgitation maximum velocity 0.55 (0.44-0.65), and inferior vena cava diameter 0.60 (0.49-0.72). CONCLUSIONS: ICU trainees showed very high overall agreement with experts on left ventricular function and substantial agreement for most secondary outcomes. This is the first study to assess echocardiography accuracy in Australian ICU trainees.

Duration of therapy recommended for bacteraemic illness varies widely amongst clinicians

The optimum duration of antimicrobial therapy would eradicate infection whilst minimising potential adverse drug effects to the patient. Australian and New Zealand infectious diseases (ID) and ICU specialists were surveyed regarding their recommended duration of antibiotic treatment for five common bacteraemic syndromes. A total of 239 clinicians responded to the survey (15.5% ICU and 84.5% ID). Overall, the most common reported durations were 7 (33.7%), 10 (25.9%) and 14 (26.0%) days, with 46% of responses recommending ≤7 days. Most respondents (>75% for each characteristic) would not modify duration based on host characteristics such as patient age or co-morbidities. ID physicians recommended longer durations than ICU physicians for all five syndromes (ID, median 10, IQR 7-14, range 1-28 days; ICU, median 7, IQR 5-10, range 2-21 days). Across all respondents, the median (IQR) duration for each syndrome was: CVC-BSI, 7 (7-10) days; bacteraemic pneumonia, 7 (7-10) days; bacteraemic UTI, 10 (7-14) days; bacteraemic IAI, 7 (7-12) days; and bacteraemic SSTI, 10 (7-14) days. Marked variation exists amongst clinicians' recommended duration of antibiotic treatment for BSI. A proportion of clinicians recommend therapy of ≤7 days at present (33.3-59.7% across scenarios). Patient characteristics are not strongly considered in the decision on therapy duration. This survey was undertaken as preparatory work for initiation of the BALANCE study, an ongoing randomised trial comparing 7 days with 14 days of therapy for BSI, providing an evidence base to inform best clinical treatment for this patient population.

Prediction of ICU Delirium: Validation of Current Delirium Predictive Models in Routine Clinical Practice.

To investigate the ability of available delirium risk assessment tools to identify patients at risk of delirium in an Australian tertiary ICU. Prospective observational study. An Australian tertiary ICU. All patients admitted to the study ICU between May 8, 2017, and December 31, 2017, were assessed bid for delirium throughout their ICU stay using the Confusion Assessment Method for ICU. Patients were included in this study if they remained in ICU for over 24 hours and were excluded if they were delirious on ICU admission, or if they were unable to be assessed using the Confusion Assessment Method for ICU during their ICU stay. Delirium risk was calculated for each patient using the prediction of delirium in ICU patients, early prediction of delirium in ICU patients, and Lanzhou models. Data required for delirium predictor models were obtained retrospectively from patients medical records. None. There were 803 ICU admissions during the study period, of which 455 met inclusion criteria. 35.2% (n = 160) were Confusion Assessment Method for ICU positive during their ICU admission. Delirious patients had significantly higher Acute Physiology and Chronic Health Evaluation III scores (median, 72 vs 54; p < 0.001), longer ICU (median, 4.8 vs 1.8 d; p < 0.001) and hospital stay (16.0 vs 8.16 d; p < 0.001), greater requirement of invasive mechanical ventilation (70% vs 21.4%; p < 0.001), and increased ICU mortality (6.3% vs 2.4%; p = 0.037). All models included in this study displayed moderate to good discriminative ability. Area under the receiver operating curve for the prediction of delirium in ICU patients was 0.79 (95% CI, 0.75-0.83); recalibrated prediction of delirium in ICU patients was 0.79 (95% CI, 0.75-0.83); early prediction of delirium in ICU patients was 0.72 (95% CI, 0.67-0.77); and the Lanzhou model was 0.77 (95% CI, 0.72-0.81). The predictive models evaluated in this study demonstrated moderate to good discriminative ability to predict ICU patients' risk of developing delirium. Models calculated at 24-hours post-ICU admission appear to be more accurate but may have limited utility in practice.

Implementation of the Critical Care Pain Observation Tool increases the frequency of pain assessment for noncommunicative ICU patients

BackgroundPain is a common stressor for ICU patients, necessitating routine assessment. For patients who are unable to communicate, self-report tools are unsuitable, and the use of an observational tool is required to assess pain appropriately. The Critical Care Pain Observation Tool (CPOT) is the most reliable tool currently available to assess pain in these patients. We investigated whether the implementation of the CPOT in one Australian ICU could increase frequency of appropriate pain assessments, and if this would affect the administration of analgesia and sedation. MethodsIn this before and after study, we first performed a retrospective chart audit on 441 adult ICU patient charts, over 49 days. Data collected included frequency and type of pain assessments, sedation and analgesia administered, communication and CAM-ICU status, and bedside nurse-perceived pain. During the implementation phase, new policy and guideline documents were released, and ICU charts were redesigned to incorporate the CPOT. All nursing staff attended an education session on pain assessment and correct use of the CPOT. The chart audit was repeated, capturing 344 charts over 43 days. ResultsMean total assessments in 24 hours increased from 7.2 to 7.9 for communicative, 3.0 to 8.9 for non-communicative, and 5.1 to 9.1 for transitioning patients. For non-communicative patients there was a significant increase in observational assessments including the CPOT (1.7 to 8.3), and a decrease in inappropriate use of self-report tools (1.3 to 0.2). We also observed significant increases in administration of paracetamol, opiates, propofol, patient-controlled analgesia, modified-release opiates, and neuropathic pain agents. ConclusionsImplementation of the CPOT using standardised education and resources led to increased frequency of pain assessment, particularly for non-communicative patients. Appropriate observational assessments were also more frequently used for these patients. Analgesic administration generally increased, as did the use of propofol.

Heightened emotional vulnerability and regaining control: A grounded theory of family resilience in an Australian ICU

Heightened emotional vulnerability and regaining control: A grounded theory of family resilience in an Australian ICU

Using frailty to predict mortality in Australian ICU patients following trauma: A prospective observational study comparing two frailty measures

Using frailty to predict mortality in Australian ICU patients following trauma: A prospective observational study comparing two frailty measures

Are Australian ICU patients more overweight than the general population, and is it important: a single site observational study?

Are Australian ICU patients more overweight than the general population, and is it important: a single site observational study?

Determining the duration of mechanical ventilation in a South Australian ICU: A retrospective study

Determining the duration of mechanical ventilation in a South Australian ICU: A retrospective study

Abstract PR088

Background & Objectives: Proportional Assist Ventilation (PAV+) delivers positive pressure ventilation in proportion to instantaneous inspiratory effort, with some studies suggesting PAV+ may reduce ventilator dyssynchrony and the duration of weaning from the ventilator. This trial compared the time taken to wean critically ill patients from invasive mechanical ventilation using PAV+ as opposed to Pressure Support Ventilation (PSV). Secondary objectives were to compare the rate of tracheostomy, failed extubation, ICU and hospital length of stay (LOS), ICU and hospital mortality in patients studied. Materials & Methods: This study was conducted in a 15-bed Australian metropolitan ICU that admits approximately 1100 medical and surgical patients per year. Patients were included in the study if they had been ventilated on a controlled mode of ventilation and were deemed suitable for at least 48 hours of weaning on a spontaneous mode of ventilation. Patients were excluded if they were unlikely to survive for 24 hours, had a neuromuscular disease or injury, or a tracheostomy in-situ. Results: Fifty patients were randomised, with 25 randomised into each arm. There was no statistical difference in age (median = 65 vs 61 years; p = 0.76) and APACHE-III illness severity score (median = 76 vs 77.5, p = 0.75) between the PAV+ and PSV groups. There was no significant difference in the duration of weaning from mechanical ventilation (78.2 vs 130.5 hours; p = 0.53). There was a non-significant trends towards lower in-hospital mortality (12% vs 37.5%, p = 0.08). There was no significant difference in the ICU LOS (median = 9.3 vs. 11.8 days; p = 0.57) among patients in the PAV+ arm when compared to those in the PSV arm. Three patients in the PAV+ group did not respond to this ventilation mode and were changed to PSV. There was no significant difference in the proportion of patients requiring tracheostomy (20% vs 29.2%; p = 0.68) or reintubation (4% vs 8.3%; p = 0.97). Conclusion: The duration of weaning from mechanical ventilation was comparable with PAV+ and PSV ventilation. A trend towards reduced hospital mortality was noted with PAV+ weaning. A larger study may provide further information on the advantages and disadvantages of PAV+ compared to other modes of spontaneous ventilation.

Overcoming barriers to the mobilisation of patients in an intensive care unit.

We conducted a quality improvement project aimed at increasing the frequency of mobilisation in our ICU. We designed a four-part quality improvement project comprising: an audit documenting the baseline frequency of mobilisation; a staff survey evaluating perceptions of the barriers to mobilisation; identification of barriers that were amenable to change and implementation of strategies to address these; and a follow-up audit to determine their effectiveness. The setting was a tertiary care, urban, public hospital ICU in South Australia. All patients admitted to the ICU during the two audit periods were included in the audits, while all permanent/semi-permanent ICU staff were eligible for inclusion in the staff survey. We found that patient- and institution-related factors had the greatest impact on the mobilisation of patients in our ICU. Barriers identified as being amenable to change included insufficient staff education about the benefits of mobilisation, poor interdisciplinary communication and lack of leadership regarding mobilisation. Various strategies were implemented to address these barriers over a three-month period. Multivariable analyses showed that three out of four mobility outcomes did not significantly change between the baseline and follow-up audits, with a significant difference in favour of the baseline audit found for the fourth mobility outcome (maximum level of mobility). We concluded that implementing relatively simple measures to improve staff education, interdisciplinary communication and leadership regarding early progressive mobilisation was ineffective at improving mobility outcomes for patients in a large tertiary-level Australian ICU. Other strategies, such as changing sedation practices and/or increasing staffing, may be required to improve mobility outcomes of these patients.

Usual Care Physiotherapy During Acute Hospitalization in Subjects Admitted to the ICU: An Observational Cohort Study.

Physiotherapists play an important role in the provision of multidisciplinary team-based care in the ICU. No studies have reported usual care respiratory management or usual care on the wards following ICU discharge by these providers. This study aimed to investigate usual care physiotherapy for ICU subjects during acute hospitalization. One hundred subjects were recruited for an observational study from a tertiary Australian ICU. The frequency and type of documented physiotherapist assessment and treatment were extracted retrospectively from medical records. The sample had median (interquartile range) APACHE II score of 17 (13-21) and was mostly male with a median (interquartile range) age of 61 (49-73) y. Physiotherapists reviewed 94% of subjects in the ICU (median of 5 [3-9] occasions, median stay of 4.3 [3-7] d) and 89% of subjects in acute wards (median of 6 [2-12] occasions, median stay of 13.3 [6-28] d). Positioning, ventilator lung hyperinflation, and suctioning were the most frequently performed respiratory care activities in the ICU. The time from ICU admission until ambulation from the bed with a physiotherapist had a median of 5 (3-8) d. The average ambulation distance per treatment had a median of 0 (0-60) m in the ICU and 44 (8-78) m in the acute wards. Adverse event rates were 3.5% in the ICU and 1.8% on the wards. Subjects received a higher frequency of physiotherapy in the ICU than on acute wards. Consensus is required to ensure consistency in data collection internationally to facilitate comparison of outcomes.

Persistent critical illness characterised by Australian and New Zealand ICU clinicians

Persistent critical illness characterised by Australian and New Zealand ICU clinicians

ECMO in an Australian tertiary ICU: A four year review

ECMO in an Australian tertiary ICU: A four year review