Australian Intensive Care Unit Research Articles

Use of a concentrated enteral nutrition solution to increase calorie delivery to critically ill patients: a randomized, double-blind, clinical trial

Critically ill patients typically receive ∼60% of estimated calorie requirements. We aimed to determine whether the substitution of a 1.5-kcal/mL enteral nutrition solution for a 1.0-kcal/mL solution resulted in greater calorie delivery to critically ill patients and establish the feasibility of conducting a multicenter, double-blind, randomized trial to evaluate the effect of an increased calorie delivery on clinical outcomes. A prospective, randomized, double-blind, parallel-group, multicenter study was conducted in 5 Australian intensive care units. One hundred twelve mechanically ventilated patients expected to receive enteral nutrition for ≥2 d were randomly assigned to receive 1.5 (n = 57) or 1.0 (n = 55) kcal/mL enteral nutrition solution at a rate of 1 mL/kg ideal body weight per hour for 10 d. Protein and fiber contents in the 2 solutions were equivalent. The 2 groups had similar baseline characteristics (1.5 compared with 1.0 kcal/mL). The mean (±SD) age was 56.4 ± 16.8 compared with 56.5 ± 16.1 y, 74% compared with 75% were men, and the Acute Physiology and Chronic Health Evaluation II score was 23 ± 9.1 compared with 22 ± 8.9. The groups received similar volumes of enteral nutrition solution [1221 mL/d (95% CI: 1120, 1322 mL/d) compared with 1259 mL/d (95% CI: 1143, 1374 mL/d); P = 0.628], which led to a 46% increase in daily calories in the group given the 1.5-kcal/mL solution [1832 kcal/d (95% CI: 1681, 1984 kcal/d) compared with 1259 kcal/d (95% CI: 1143, 1374 kcal/d); P < 0.001]. The 1.5-kcal/mL solution was not associated with larger gastric residual volumes or diarrhea. In this feasibility study, there was a trend to a reduced 90-d mortality in patients given 1.5 kcal/mL [11 patients (20%) compared with 20 patients (37%); P = 0.057]. The substitution of a 1.0- with a 1.5-kcal/mL enteral nutrition solution administered at the same rate resulted in a 46% greater calorie delivery without adverse effects. The results support the conduct of a large-scale trial to evaluate the effect of increased calorie delivery on clinically important outcomes in the critically ill.

Impact of delirium and suture-less securement on accidental vascular catheter removal in the ICU.

The objectives were to describe the incidence of accidental vascular catheter removal (AVCR) in an Australian Intensive Care Unit (ICU) and evaluate whether the fixation method or patient delirium increased the risk of AVCR. This prospective observational study was based in a tertiary level ICU between April 2011 and October 2012. All vascular catheters were secured either by sutures or by a suture-less securement device (STATLOCK(™), Bard Medical, Covington, GA, USA) as per the treating clinician. Data were obtained from bedside nursing staff, with daily screening for delirium completed by the ICU medical team using the Confusion Assessment Method-ICU. 2361 patients were admitted during this period with 1032 patients screened and data available for 322 patients (452 vascular catheters). AVCR occurred in 15 patients (16 vascular catheters) (5.0%) with an incidence of AVCR of 2.77 per 100 catheter-days. Delirious patients were 13-fold more likely to have an AVCR event (odds ratio=13.3; 95% confidence interval 4.36, 40.52; P <0.0001). There was a non-significant trend to an increase in AVCR when using the suture-less securement device (odds ratio=2.6; 95% confidence interval 0.87, 7.8; P=0.09) but delirious patients were no more likely to have an AVCR episode when a suture-less securement device was used (P=0.95). In this study the use of suture-less securement did not seem to increase the risk of AVCR. However, there was a non-significant trend towards increased AVCR when using suture-less securement devices, which may reflect a ß error.

The physical function intensive care test: implementation in survivors of critical illness.

Recent studies have demonstrated safety, feasibility, and decreased hospital length of stay for patients with weakness acquired in the intensive care unit (ICU) who receive early physical rehabilitation. The scored Physical Function in Intensive Care Test (PFIT-s) was specifically designed for this population and demonstrated excellent psychometrics in an Australian ICU population. The purpose of this study was to determine the responsiveness and predictive capabilities of the PFIT-s in patients in the United States admitted to the ICU who required mechanical ventilation (MV) for 4 days or longer. This nested study within a randomized trial administered the PFIT-s, Medical Research Council (MRC) sum score, and grip strength test at ICU recruitment and then weekly until hospital discharge, including at ICU discharge. Spearman rho was used to determine validity. The effect size index was used to calculate measurement responsiveness for the PFIT-s. The receiver operating characteristic curve was used in predicting participants' ability to perform functional components of the PFIT-s. From August 2009 to July 2012, 51 patients were recruited from 4 ICUs in the Denver, Colorado, metro area. At ICU discharge, PFIT-s scores were highly correlated to MRC sum scores (rho=.923) and grip strength (rho=.763) (P<.0005). Using baseline test with ICU discharge (26 pairs), test responsiveness was large (1.14). At ICU discharge, an MRC sum score cut-point of 41.5 predicted participants' ability to perform the standing components of the PFIT-s. The small sample size was a limitation. However, the findings are consistent with those in a larger sample from Australia. The PFIT-s is a feasible and valid measure of function for individuals who require MV for 4 days or longer and who are alert, able to follow commands, and have sufficient strength to participate.

Characteristics of obstetric patients referred to intensive care in an Australian tertiary hospital.

The low mortality rate of 8.4 deaths per 100,000 women giving birth in Australia is well described; however, less is known about the spectrum of morbidity evident in pregnant and postpartum women admitted to an intensive care unit. A detailed description of the demographics, comorbidities, diagnoses and interventions of pregnant and postpartum women admitted to an Australian intensive care unit (ICU). A retrospective observational study was conducted in a large metropolitan hospital co-located with a quaternary-level maternity hospital. The participants were women admitted to intensive care between 1 January 2007 and 30 June 2009 who were pregnant at any gestational age, or within 6 weeks postpartum. Two hundred and forty-nine women were admitted to ICU within the study period constituting 19% of all ICU admissions. The main reasons for admission were hypertensive disease of pregnancy and obstetric haemorrhage. The median (range) age was 32 (17-51) years, and ICU duration was 32 (8-228) h. The median APACHE III-J severity of illness score was 32 (8-80). Almost one-quarter of admissions could be classified as primarily observational. The most common interventions in ICU were invasive arterial pressure monitoring, central venous access with pressure monitoring and magnesium infusions. One-fifth of admissions were invasively ventilated. A substantial number of pregnant and postpartum women admitted to ICU did not receive interventions typical of other critical illness, such as mechanical ventilation, inotropes or renal replacement therapy. This confounds the use of an ICU admission as a measure of maternal morbidity.

Quality of life post extracorporeal membrane oxygenation in one Australian intensive care unit

Quality of life post extracorporeal membrane oxygenation in one Australian intensive care unit

Variability of infusion preparation in Australian and New Zealand intensive care units

Variability of infusion preparation in Australian and New Zealand intensive care units

Impact of introducing a maternity observation and response chart

s / Australian Critical Care 27 (2014) 43–63 57 Impact of introducing a maternity observation and response chart A. Doric ∗, V. Watkins Eastern Health, Australia Introduction: Pregnancy and childbearing is generally a normal life event for a healthy woman. Serious illness in pregnancy and childbearing can be insidious in onset and difficult to recognise due to the compensatory mechanisms of pregnancy. Objectives: In order to improve recognition of deterioration for childbearing women, a maternity observation and response chart was developed using the current evidence base and experience from case studies. Methods: Cases of clinical deterioration in childbearing women in our health network were analysed using audit of WHOMaternal Near Miss (MNM) criteria over the preceding 24 months. A review of existing maternity observation charts revealed linear recording of vital signs with no space to record respiratory rate or fundal height. Observation and escalation criteria for childbearing women were revised to detect early deterioration and then incorporated into observation charts. Following education and clinical support for maternity staff, the observation charts and obstetric escalation criteria were introduced in November 2011. Results: Haemorrhage (66%) and sepsis (21%) were identified as the most common conditions leading to serious clinical deterioration meeting MNM criteria of childbearing women in our health service. Early warning signs of impending deterioration most frequently included respiratory dysfunction, increasinguterine fundal height, heavy postnatal lochia, pain, and ‘looks unwell’. These signs often appeared prior to deterioration in blood pressure or heart rate. The maternity observation charts and escalation criteria have been in use for over 18 months. To date we have seen an increased rate of systematic observation and documentation of the vital signs and clinical status of childbearing women post birth. The charts have also supported clinicians’ decision making and empowered midwives to escalate care when required. In addition, these charts are anobjective tool to assist in the identificationof barriers to early recognition and response to clinical deterioration, so thatmeasures can be adopted to address these issues at an organisational level. Conclusions:The introduction of thematernity observation and response chart and associated escalation criteria are contributing to early and improved recognition and response to clinical deterioration in childbearing women across our health network. http://dx.doi.org/10.1016/j.aucc.2013.10.044 Tissue adhesive—A novel approach to the securement of intra-arterial catheters? A randomised controlled pilot study M. Edwards1,∗, C. Rickard1,2, I. Rapchuk1, A. Corley1,2, N. Marsh2, A. Spooner1,2, G. Mihala2, J. Fraser1,2 1 Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Queensland, Australia 2 Intravascular Access Device Research Group, NHMRC Centre for Research Excellence in Nursing Interventions for Hospitalised Patients, Griffith Health Institute, Queensland, Australia Critically ill patients typically require peripheral intra-arterial catheters (IALs), yet current catheter securement methods are not always adequate—leading to catheter failure and repeated insertions. This study aimed to identify the best securement method to prevent IAL failure. A randomised, controlled, non-blindedpilot trialwas conducted at a tertiary hospital. After informed consent, 217 patients were randomised to: (i) tissue adhesive (TA), (ii) bordered polyurethane (BPU), (iii) sutureless securement device (SSD), or (iv) control. All groups received standard polyurethane dressing (SPU). In controls, SPU was the only product used. The primary endpoint was IAL failure defined as any of: dislodgement (complete), occlusion (monitor failure, cannot infuse, or fluid leakingwhen infused), pain, or infection (local or bloodstream infection). The median IAL dwell time was 26h (IQR: 23–45). Catheter failure was not statistically different between groups (p=0.12), occurring at rates of 1.2 (SPU), 1.3 (BPU, p=0.94), 4.7 (SSD, p=0.08), and 2.8 (TA, p=0.50) per 1000 catheter hours. The SPU control dressing was problematic with clinical staff holding serious concerns about the safety of these dressings in eight patients resulting in their early study completion (censoring). There were no infections in any group. SPU dressings used alone are problematic. The addition of new product classes such as BPU or SSD, or the novel approach of TA could improve outcomes for patients with IALs. Further research is now underway to test these approaches in a large multi-site study. http://dx.doi.org/10.1016/j.aucc.2013.10.046 Development of a multi-disciplinary communication tool (MdCT) for long stay patients in the intensive care unit (ICU) D. Housiaux1,∗, T. Bucknall 1,2, C. Bell 1, K.J. Farley1, J. Sheldrake1 1 Alfred Hospital, Australia 2 Deakin University, Australia Introduction: Evidence reveals that 2.3% of ICU patients have a length of stay (LOS) greater than 21 days, representing 23% of ICU bed hour usage. These long-stay ICU patients have significant physical and psychological needs that require a co-ordinated approach from a multi-disciplinary team. Objectives: 1) Analyse the literature to identify factors influencing long term patient management. 2) Identify tools that improve communication, patient management and patient outcomes. 3) Develop a MdCT relevant to Australian ICUs.

Have a safe journey.

In the modern era of reliable communication systems and relatively safe modes of transport the wish - “have a safe journey” still has relevance. The article by Venkategowda in this issue of the journal[1] shows that even short journeys inside the hospital are commonly eventful. Prior publications in India have addressed related issues in neonates from distant places to hospital, and a high mortality associated with transfer has been reported.[2] Patients are older and sicker; there is more need for imaging studies, and hence transport to and from intensive care unit (ICU) has increased. In mechanically ventilated patients, transport out of ICU for diagnostic purposes is common; transfer rates up to 52% have been reported[3] and have been associated with increasing risks of ventilator associated pneumonia. The current article reports an unexpected event (UE) rate of one for every four patient transfers and some patients had more than one UE. Most UEs were of a minor nature and none were life threatening. A similar larger exercise has been reported from Australian ICUs from the years 1993 to 1999.[4] The strength of this study was that incident reports were in an anonymous fashion, which could have led to greater capture of all events. An attempt was also made in the study to classify the factors contributing to the errors as system-based and human-based errors. The message of the current study would have been strengthened if the cause of the UE's could have been apportioned to training, protocol violation, procedural skill, and communication issues. Medical training in India and elsewhere has, for too long, paid undue emphasis on individual skill development in diagnostic and procedural tasks. It is assumed that with the acquisition of these skills, high quality processes and good outcomes will naturally follow. The “watch one, do one, and teach one” motto[5] in residency training has not been replaced with formal assessment and supervised training in complex simulated ICU conditions. All of this has acquired increasing relevance due to the complexity of cases, and increasing number of patients requiring intensive care and its associated procedures. An ICU patient may require 178 individual tasks per day each of which is prone to error.[6] Safety and quality in medicine has been shown to improve after following principles first adopted in aircraft engineering. The checklist approach has been documented to improve outcomes in intensive care.[6] For a checklist approach to work, baseline data has to be captured. The current study is a first step in the acquisition of data with respect to the safety of intrahospital transport in ICU patients. Larger studies of anonymous reports with standard formats of error classification will aid in the development of efficient protocols and benchmarks for the safe transport of ICU patients.

Effect of intensive care after cardiac arrest on patient outcome: a database analysis

IntroductionThe study aimed to determine the impact of treatment frequency, hospital size, and capability on mortality of patients admitted after cardiac arrest for postresuscitation care to different intensive care units.MethodsProspectively recorded data from 242,588 adults consecutively admitted to 87 Austrian intensive care units over a period of 13 years (1998 to 2010) were analyzed retrospectively. Multivariate analysis was used to assess the effect of the frequency of postresuscitation care on mortality, correcting for baseline parameters, severity of illness, hospital size, and capability to perform coronary angiography and intervention.ResultsIn total, 5,857 patients had had cardiac arrest and were admitted to an intensive care unit. Observed hospital mortality was 56% in the cardiac-arrest cohort (3,302 nonsurvivors). Patients treated in intensive care units with a high frequency of postresuscitation care generally had high severity of illness (median Simplified Acute Physiology Score (SAPS II), 65). Intensive care units with a higher frequency of care showed improved risk-adjusted mortality. The SAPS II adjusted, observed-to-expected mortality ratios (O/E-Ratios) in the three strata (<18; 18 to 26; >26 resuscitations per ICU per year) were 0.869 (95% confidence interval, 0.844 to 894), 0.876 (0.850 to 0.902), and 0.808 (0.784 to 0.833).ConclusionsIn this database analysis, a high frequency of post-cardiac arrest care at an intensive care unit seemed to be associated with improved outcome of cardiac-arrest patients. We were able to identify patients who seemed to profit more from high frequency of care, namely, those with an intermediate severity of illness. Considering these findings, cardiac-arrest care centers might be a reasonable step to improve outcome in this specific population of cardiac-arrest patients.

Abstract 247: Effect of Post Resuscitation Care Frequency on Outcome After Cardiac Arrest

Determination of the impact of the treatment frequency, hospital size and capability on mortality of patients admitted after cardiac arrest for post resuscitation care to different intensive care units in Austria. Methods: Prospectively recorded data from 242,588 adults consecutively admitted to 87 Austrian intensive care units over a period of 13 years (1998-2010) were analyzed retrospectively. Results: In total 5,857 patients had suffered cardiac arrest and were admitted to an intensive care unit for post resuscitation care. Observed hospital mortality was 15% in the non cardiac arrest cohort (36,460 non survivors) and 56% in the cardiac arrest cohort (3302 non survivors; p&lt;0.0001). Patients treated in intensive care units with a high frequency of post resuscitation care generally had higher severity of illness. Intensive care units with a higher frequency of post resuscitation care showed improved risk adjusted mortality. The SAPS II adjusted, observed to expected mortality ratios (O/E-Ratios) in the three strata (less than &lt;18; 18 to 26; more than 26 resuscitations per ICU per year) were 0.869 (95-%-confidence interval: 0.844 - 894), 0.876 (0.850 - 0.902) and 0.808 (0.784 - 0.833). Conclusions: Intensive care units, providing post resuscitation care at a high frequency, were associated with improved outcome. Establishing cardiac arrest care centers might be a reasonable step to improve outcome after cardiac arrest.

Timing of Blood Transfusion in Relation to ICU Admission— A Single Centre Audit

There is growing concern that blood transfusion may be associated with adverse outcomes in critically ill patients. Timing of transfusion in relation to intensive care unit (ICU) stay may be important in designing and understanding transfusion studies. The objective of this study was to determine the timing of red blood cell transfusion in relation to admission to an Australian ICU and to describe associations with transfusion requirements. We undertook a retrospective, observational, single-centre cohort study of all patients admitted to the ICU at The Northern Hospital, Melbourne, Australia, between 1 January and 31 December 2008 in order to measure the timing of transfusion in relation to ICU admission and the demographic and outcome data of the cohort. 674 individual hospital admissions were analysed. Overall, 28% (188/674) of patients admitted to ICU received a red cell transfusion during their hospital stay. A total of 55 (28.5%) patients were transfused either before and/or after ICU discharge but never in the ICU. Thirty-five percent (258/741) of red cell units were transfused outside the ICU. The median number of red cell units transfused was three units per patient (interquartile range 1 to 5). There was no difference between transfused and non-transfused groups in either crude mortality or severity-adjusted mortality. In approximately one-third of ICU patients in our study transfusions occurred before admission to, and/or after discharge from, the ICU. This has implications for designing and interpreting transfusion studies in the ICU and requires confirmation in a multi-centre study.

CNE Article: Safety Culture In Australian Intensive Care Units: Establishing A Baseline For Quality Improvement

Workplace safety culture is a crucial ingredient in patients' outcomes and is increasingly being explored as a guide for quality improvement efforts. To establish a baseline understanding of the safety culture in Australian intensive care units. In a nationwide study of physicians and nurses in 10 Australian intensive care units, the Safety Attitudes Questionnaire intensive care unit version was used to measure safety culture. Descriptive statistics were used to summarize the mean scores for the 6 subscales of the questionnaire, and generalized-estimation-equations models were used to test the hypotheses that safety culture differed between physicians and nurses and between nurse leaders and bedside nurses. A total of 672 responses (50.6% response rate) were received: 513 (76.3%) from nurses, 89 (13.2%) from physicians, and 70 (10.4%) from respondents who did not specify their professional group. Ratings were highest for teamwork climate and lowest for perceptions of hospital management and working conditions. Four subscales, job satisfaction, teamwork climate, safety climate, and working conditions, were rated significantly higher by physicians than by nurses. Two subscales, working conditions and perceptions of hospital management, were rated significantly lower by nurse leaders than by bedside nurses. Measuring the baseline safety culture of an intensive care unit allows leaders to implement targeted strategies to improve specific dimensions of safety culture. These strategies ultimately may improve the working conditions of staff and the care that patients receive.

Establishing a Culture of Safety

Patient safety has taken an increasingly prominent place in the acute and critical care environments in the past 10 years, culminating in efforts to establish a culture of safety in every facility. In 2002, The Joint Commission announced the first set of National Patient Safety Goals that required each organization to review policies, procedures, and processes embedded within the culture to ensure compliance with the goals. Today, quality improvement efforts permeate individual critical care and acute care units. Patient safety experts emphasize that improved patient outcomes can only be sustained if a culture of safety is present throughout all levels of a health care organization. Chaboyer and colleagues examined attitudes about safety among various disciplines in Australian intensive care units. There were variations in the responses among bedside nurses, nurse leaders, and physicians, but all the responding units indicated that the key areas needing improvement were communication and teamwork, staffing, education and training, and physical resources. The results from this study are similar to studies conducted in health care organizations in the United States.

Viral Pneumonitis Is Increased in Obese Patients during the First Wave of Pandemic A(H1N1) 2009 Virus

IntroductionThere is conflicting data as to whether obesity is an independent risk factor for mortality in severe pandemic (H1N1) 2009 influenza (A(H1N1)pdm09). It is postulated that excess inflammation and cytokine production in obese patients following severe influenza infection leads to viral pneumonitis and/or acute respiratory distress syndrome.MethodsDemographic, laboratory and clinical data prospectively collected from obese and non-obese patients admitted to nine adult Australian intensive care units (ICU) during the first A(H1N1)pdm09 wave, supplemented with retrospectively collected data, were compared.ResultsOf 173 patients, 100 (57.8%), 73 (42.2%) and 23 (13.3%) had body mass index (BMI) <30 kg/m2, ≥30 kg/m2 (obese) and ≥40 kg/m2 (morbidly obese) respectively. Compared to non-obese patients, obese patients were younger (mean age 43.4 vs. 48.4 years, p = 0.035) and more likely to develop pneumonitis (61% vs. 44%, p = 0.029). Extracorporeal membrane oxygenation use was greater in morbidly obese compared to non-obese patients (17.4% vs. 4.7%, p = 0.04). Higher mortality rates were observed in non-obese compared to obese patients, but not after adjusting for severity of disease. C-reactive protein (CRP) levels and hospital length of stay (LOS) were similar. Amongst ICU survivors, obese patients had longer ICU LOS (median 11.9 vs. 6.8 days, p = 0.017). Similar trends were observed when only patients infected with A(H1N1)pdm09 were examined.ConclusionsAmong patients admitted to ICU during the first wave of A(H1N1)pdm09, obese and morbidly obese patients with severe infection were more likely to develop pneumonitis compared to non-obese patients, but mortality rates were not increased. CRP is not an accurate marker of pneumonitis.

Patients admitted to Australian intensive care units: impact of remoteness and distance travelled on patient outcome

Patients admitted to Australian intensive care units: impact of remoteness and distance travelled on patient outcome

Performance of Apache III over Time in Australia and New Zealand: A Retrospective Cohort Study

The Acute Physiology and Chronic Health Evaluation (APACHE) III-j model has been used for benchmarking intensive care unit (ICU) outcomes in Australia and New Zealand for over a decade. This study assessed performance of the APACHE III-j model in adult patients admitted to Australasian ICUs during a ten-year period. Data were extracted from the Australian and New Zealand Intensive Care Society Adult Patient Database. Performance of APACHE III-j at different time points and within different age strata was evaluated by dividing the whole cohort into five 'two-year' groups. Calibration and discrimination were assessed by the Brier score, Hosmer-Lemeshow C and H statistics, Standardised Mortality Ratio (SMR), Cox calibration regression, calibration curves and area under the receiver operating characteristic curve (AUROC). Model performance within diagnostic categories was evaluated. Between 1 January 2000 and 31 December 2009, 558,585 ICU admissions which met inclusion criteria were included in the analysis. The mean (standard deviation) age was 60.8 (18.4) years and 58.3% were male. Overall observed mortality was 12.6%. The mean (standard deviation) APACHE III-j predicted mortality was 14.5% (21.8). Although discrimination (as measured by AUROC) was preserved over time, all other markers of model performance showed deterioration. There was a significant decrease in SMR in eight of ten most common diagnoses examined. This study demonstrates that performance of APACHE III-j model has deteriorated in Australasian hospitals and there is now a clear need for an updated modelling approach to improve mortality prediction, performance monitoring and quality of research undertaken in Australian and New Zealand ICUs.

Early diagnosis and treatment of necrotizing fasciitis can improve survival: an observational intensive care unit cohort study

The aim of this study was to describe the clinical characteristics, causative pathogens, clinical management and outcomes of patients presenting to a tertiary adult Australian intensive care unit (ICU) with a diagnosis of necrotizing fasciitis (NF). This retrospective observational study was conducted in a 19-bed, level III, adult ICU in a 450-bed tertiary, regional hospital. Clinical databases were accessed for patients diagnosed with NF and admitted to The Geelong Hospital ICU between 1 February 2000 and 1 June 2011. Information on severity of sepsis, surgical procedures and microbiological results were collected. Twenty patients with NF were identified. The median age was 52.5 years and 38% were female. The overall mortality rate was 8.3%. Common co-morbidities were diabetes (21%) and heart failure (17%), although 50% of patients had no co-morbidities. Group A Streptococcus was the identified pathogen in 11 (46%) patients, and Streptococcus milleri group in 5 (21%) patients. Hyperbaric oxygen therapy was not used in the majority of patients. The initial antibiotics administered were active against subsequently cultured bacteria in 83% of patients. Median time to surgical debridement was 20 h. Diagnosis and management was delayed in the nosocomial group. This study reports physiological data, aetiology and therapeutic interventions in NF for an adult tertiary hospital. We demonstrate one of the lowest reported mortality rates, with early surgical debridement being achieved in the majority of patients. The main delay was found to be in the diagnosis of NF.

A national survey of Australian Intensive Care Unit (ICU) Liaison Nurse (LN) services

The Intensive Care Unit (ICU) Liaison Nurses (LNs) emerged as a member of the multidisciplinary team to: assist in the transition of patients from ICU to the ward, respond to the deteriorating patient in an appropriate and timely manner, and in some instances act as an integral member of Rapid Response Teams (RRT). To identify the common core aspects and diversity within the ICU LN role across Australia and to determine whether the ICU LN hours of operation and the participation in MET teams has any impact on the activities undertaken by the ICU LN. This descriptive survey of 152 Australian ICUs was conducted in April 2010. The Advanced Practice Nurse (APN) framework was used to develop the survey instrument, which comprised of four scales, education (5 items), collaboration (6 items), practice (8 items) research and quality (6 items) and a number of demographic questions. Descriptive statistics (mean, standard deviation (SD), median, interquartile ranges (IQR) and frequency) were used to summarise the data. Student's t-tests and Pearson's correlations were used to test the hypotheses. Surveys were received from 113 hospitals (55 metropolitan, 58 regional): a 74% response rate. ICU LN services operated in 31 (27%) of these hospitals. LN services tended to operate in larger hospitals with higher ICU admission rates. The median weekly hours of operation was 56 (IQR 30; range 7-157), delivered by a median of 1.4 (IQR 0.9; range 0.0-4.2) Full Time Equivalent (FTE) staff. The median weekly patient visits made by the LN was 25 (IQR 44; range 2-145). The LN was reported to be a member of the Medical Emergency Team (MET) in 17 (68%) of the 25 hospitals that provided both MET and ICU LN services. The ICU LN activities were grouped under four key Advanced Practice Nurse (APN) domains: education, collaboration, practice and research/quality. Mean scale scores were calculated for each APN domain. The ICU LN reported being involved in activities associated with all four APN domains, and more frequently they were involved in education and expert practice during their daily work. Neither the presence of a MET nor the weekly operational hours of the LN service significantly affected the key activities undertaken by ICU LNs (education, collaboration, practice, research and quality). Whilst many hospitals across Australia have introduced an ICU LN service, the staffing, hours of service, job classifications, reporting lines, referral processes and APN activities undertaken by the ICU LN, vary between hospitals, highlighting the diverse nature of ICU LN services across Australia.

Development of demographics and outcome of very old critically ill patients admitted to intensive care units

To evaluate the development of demographics and outcome of very old (>80 years) critically ill patients admitted to intensive care units. All consecutive patients admitted to 41 Austrian intensive care units (ICUs) over an 11-year period. We performed a retrospective cohort study of prospectively collected data. To compare parameters over time, patients were divided into three groups (group I from 1998 until 2001, group II from 2002 to 2004, and group III from 2005 to 2008). A total of 17,126 patients older than 80 years of age were admitted over the study period. The proportion of very old patients increased from 11.5% (I) to 15.3% (III) with a significant higher prevalence of females in all groups (on average 63.2%). Severity of illness also increased over time, even when corrected for age. Use of noninvasive mechanical ventilation increased over the years. However, risk-adjusted mortality rates [observed-to-expected (O/E) ratios] decreased from 1.14 [confidence interval (CI) 1.11-1.18] to 1.02 (CI 0.99-1.05). This improvement in outcome was confirmed on multivariate analysis: for every year delay in ICU admission, the odds to die decreased by 3%. Moreover, females exhibited a better outcome compared with males. The relative and absolute numbers of very old patients increased over the study period, as did the severity of illness. Despite this, risk-adjusted hospital mortality improved over the study period. Females dominated in the very old patients and exhibited moreover a better outcome compared with males.

An ICU clinical information system - clinicians' expectations and perceptions of its impact.

The Intensive Care Unit (ICU) is an information intense environment where Clinical Information Systems (CISs) can greatly impact patient care and the workload of clinicians. With the introduction of an ICU CIS imminent across New South Wales hospitals, we aimed to understand how ICU clinicians perceived a new system would impact on work practices in Australian ICUs, as much of the current evidence is generated from overseas. We conducted interviews with 66 doctors and nurses in 3 ICUs without a CIS. Many had positive perceptions regarding the impact of its introduction, though others were more guarded and unsure. Clinicians believed information access to patient would improve, communication processes could potentially change and there was potential for work processes to be more efficient. It was expected that ward rounds and handover would be less disrupted with all information available at the bedside or at the handover setting. There were mixed responses about whether a CIS would save time and how it would influence patient care, though the majority believed a CIS would improve safety by providing a means for increasing accountability and reducing medication errors. Concerns were raised about the transition from paper to a CIS and the training required. This information provides valuable evidence in the Australian setting regarding clinicians' expectations of a new ICU CIS to assist with future implementations. It also provides baseline data as a foundation for future research once the CIS is implemented. It is clear that robust quantitative studies are required to gain a detailed understanding of how a new CIS will impact clinicians' work processes and that appropriate training is crucial for full benefits to be achieved.