Australian Intensive Care Unit Research Articles

Outcomes for older patients with subarachnoid haemorrhage who require admission to an Australian intensive care unit.

Advanced age is an independent risk factor for poor outcomes following aneurysmal subarachnoid haemorrhage (SAH). However, Australian data are lacking. Our aim was to evaluate outcomes for older patients admitted to an Australian intensive care unit for management of aneurysmal SAH. We conducted a single centre retrospective observational study looking at adult patients admitted with aneurysmal SAH to an Intensive Care Unit (ICU) over a 10-year period. Patients were grouped by age; <70 years, 70-79 years, ⩾80 years, and were of sufficient complexity to be unsuitable for our neurosurgical high-dependency unit. The primary outcome was in-hospital mortality. Secondary outcomes were ICU and hospital length of stay, and discharge destination. Of 372 patients admitted to ICU with aneurysmal SAH, 302 (82%) were younger (<70 years), 46 (12%) were septuagenarians and 24 (6%) were octogenarians. There were no differences between clinical or radiological grade of aneurysmal SAH between age cohorts. When compared to the patients younger than 70 years, there was increased odds of dying for those 70-79 and ⩾80 years (70-79: OR 1.98, 95% CI 0.93, 4.20 p = 0.077; ⩾80: OR 4.01, 95% CI 1.55, 10.35 p = 0.004). There were no associations between age and duration of admission. Only 6% of patients aged ⩾70 years were discharged home alive. It was uncommon for patients over 70 years of age who present with a SAH to be discharged home from hospital, and those aged ⩾80 are four times more likely to die in hospital than younger patients.

Intensive care unit caseload and workload and their association with outcomes in critically unwell patients: a large registry-based cohort analysis

BackgroundToo high or too low patient volumes and work amounts may overwhelm health care professionals and obstruct processes or lead to inadequate personnel routine and process flow. We sought to evaluate, whether an association between current caseload, current workload, and outcomes exists in intensive care units (ICU).MethodsRetrospective cohort analysis of data from an Austrian ICU registry. Data on patients aged ≥ 18 years admitted to 144 Austrian ICUs between 2013 and 2022 were included. A Cox proportional hazards model with ICU mortality as the outcome of interest adjusted with patients’ respective SAPS 3, current ICU caseload (measured by ICU occupancy rates), and current ICU workload (measured by median TISS-28 per ICU) as time-dependent covariables was constructed. Subgroup analyses were performed for types of ICUs, hospital care level, and pre-COVID or intra-COVID period.Results415 584 patient admissions to 144 ICUs were analysed. Compared to ICU caseloads of 76 to 100%, there was no significant relationship between overuse of ICU capacity and risk of death [HR (95% CI) 1.06 (0.99–1.15), p = 0.110 for > 100%], but for lower utilisation [1.09 (1.02–1.16), p = 0.008 for ≤ 50% and 1.10 (1.05–1.15), p < 0.0001 for 51–75%]. Exceptions were significant associations for caseloads > 100% between 2020 and 2022 [1.18 (1.06–1.30), p = 0.001], i.e., the intra-COVID period. Compared to the reference category of median TISS-28 21–30, lower [0.88 (0.78–0.99), p = 0.049 for ≤ 20], but not higher workloads were significantly associated with risk of death. High workload may be associated with higher mortality in local hospitals [1.09 (1.01–1.19), p = 0.035 for 31–40, 1.28 (1.02–1.60), p = 0.033 for > 40].ConclusionsIn a system with comparably high intensive care resources and mandatory staffing levels, patients’ survival chances are generally not affected by high intensive care unit caseload and workload. However, extraordinary circumstances, such as the COVID-19 pandemic, may lead to higher risk of death, if planned capacities are exceeded. High workload in ICUs in smaller hospitals with lower staffing levels may be associated with increased risk of death.

Epidemiology of acute hypoxaemic respiratory failure in Australian and New Zealand intensive care units during 2005–2022. A binational, registry-based study

PurposeAcute hypoxaemic respiratory failure (AHRF) is a common reason for intensive care unit (ICU) admission. However, patient characteristics, outcomes, and trends over time are unclear. We describe the epidemiology and outcomes of patients with AHRF over time.MethodsIn this binational, registry-based study from 2005 to 2022, we included all adults admitted to an Australian or New Zealand ICU with an arterial blood gas within the first 24 h of ICU stay. AHRF was defined as a partial pressure of oxygen/inspired oxygen ratio (PaO2/FiO2) ≤ 300. The primary outcome was adjusted in-hospital mortality, categorised based on PaO2/FiO2 (mild: 200–300, moderate: 100–200, and severe < 100, and non-linearly). We investigated how adjusted mortality evolved based on temporal trends (by year of admission), sex, age, admission diagnosis and the receipt of mechanical ventilation.ResultsOf 1,560,221 patients, 826,106 (52.9%) were admitted with or developed AHRF within the first 24 h of ICU stay. Of these 826,106 patients, 51.4% had mild, 39.3% had moderate, and 9.3% had severe AHRF. Compared to patients without AHRF (5.3%), patients with mild (8%), moderate (14.2%) and severe (29.9%) AHRF had higher in-hospital mortality rates. As PaO2/FiO2 ratio decreased, adjusted in-hospital mortality progressively increased, particularly below an inflection point at a PaO2/FiO2 ratio of 200. The adjusted in-hospital mortality for all patients decreased over time (13.3% in 2005 to 8.2% in 2022), and this trend was similar in patients with and without AHRF.ConclusionThe healthcare burden due to AHRF may be larger than expected, and mortality rates remain high in severe AHRF. Although mortality has decreased over time, this may reflect improvements in ICU care in general, rather than specifically in AHRF. More research is required to earlier identify AHRF and stratify these patients at risk of deterioration early, and to validate our findings.

Outcomes for people admitted to Australian and New Zealand intensive care units with primary, exacerbating, or incidental SARS-CoV-2 infections, 2022-23: a retrospective analysis of ANZICS data.

To compare in-hospital mortality and intensive care unit (ICU) length of stay for people admitted to Australian and New Zealand ICUs during 2022-23 with coronavirus disease 2019 (COVID-19) pneumonitis, incidental or exacerbating severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, or without SAR-CoV-2 infections. Retrospective cohort study; analysis of Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database data. Adults (16 years or older) admitted to participating ICUs in Australia or New Zealand, 1 January 2022- 30 June 2023. The primary outcome was in-hospital mortality, the secondary outcome ICU length of stay, each by SARS-CoV-2 infection attribution classification: primary COVID-19; exacerbating SARS-CoV-2 infection (SARS-CoV-2 infection was a contributing factor to the primary cause of ICU admission); incidental SARS-CoV-2 infections (SARS-CoV-2 infection detected during ICU admission but did not contribute to admission diagnosis); no SARS-CoV-2 infection. A total of 207 684 adults were admitted to 195 Australian and New Zealand ICUs during 2022-23; 2674 people (1.3%) had incidental SARS-CoV-2 infections, 4923 (2.4%) exacerbating infections, and 3620 (1.7%) primary COVID-19. Unadjusted in-hospital mortality for people with incidental SARS-CoV-2 infections (288 deaths, 10.8%) was lower than for those with exacerbating infections (928 deaths, 18.8%) or primary COVID-19 (830 deaths, 22.9%), but higher than for patients without SARS-CoV-2 infections (15 486 deaths, 7.9%). After adjusting for illness severity, frailty, geographic region, and type of hospital, mortality was higher for patients with incidental SARS-CoV-2 infections (adjusted odds ratio [aOR], 1.28; 95% confidence interval [CI], 1.10-1.50), exacerbating infections (aOR, 1.35; 95% CI, 1.22-1.48), or primary COVID-19 (aOR, 2.54; 95% CI, 2.30-2.81) than for patients without SARS-CoV-2 infections. After adjusting for diagnosis and illness severity, ICU stays were longer for people with incidental (mean difference, 3.3 hours; 95% CI, 2.4-4.2 hours) or exacerbating infections (0.8 hours; 95% CI, 0.2-1.5 hours) than for those without SARS-CoV-2 infections. Risk-adjusted in-hospital mortality and ICU length of stay are higher for people admitted to intensive care who have concomitant SARS-CoV-2 infections than for people who do not.

Arterial catheter outcomes in intensive care: An analysis of 1117 patients

BackgroundAccess to arterial circulation through arterial catheters (ACs) is crucial for monitoring and decision-making in intensive care units (ICU) but carries the risk of complications including bloodstream infection (BSI). MethodsWe conducted a secondary analysis of data from four randomised controlled trials in Australian ICUs, investigating the efficacy of different AC interventions. De-identified data were combined into a single dataset, and per-patient outcomes analysed. The primary outcome was AC-BSI, defined as laboratory-confirmed bloodstream infection (LCBI) type 1 or 2, with a concurrent local infection. All-cause AC failure was defined as any unplanned removal. AC infection and failure were reported as rates per 1000 catheter days and hours. ResultsData from 1117 adult patients were analysed. Mean age was 58.8 years (±16.6); and 41% (n = 462) were male. Median AC dwell time was 110 h (IQR 28.3–168.0). There was one case (<0.1%; 0.18/1000 catheter days [95% CI 0.03–1.29]) of AC-BSI, and 14 cases of LCBI (1%; 13 LCBI-1 and 1 LCBI-2; 2.54/1000 catheter days [95% CI 1.51–4.30]). LCBI were most commonly Enterococcus faecalis; Escherichia coli and Klebsiella pneumoniae. There were four cases of local infection (<1%; 0.73/1000 catheter days [95% CI 0.27–1.94]). Overall AC failure rate was 13% (n = 146) or 26.53/1000 catheter days (95% CI 22.56–31.20). ConclusionThis study identified a relatively low incidence of complications. This is likely reflective of poor monitoring of ACs in intensive care. Better surveillance and a rigorous prospective evaluation of AC outcomes is required to understand the true risk ACs pose to critically ill patients.

The impact of frailty on survival times up to one year among patients admitted to ICU with in-hospital cardiac arrest

BackgroundIn-hospital cardiac arrest (IHCA) is a serious medical emergency. When IHCA occurs in patients with frailty, short-term survival is poor. However, the impact of frailty on long-term survival is unknown. MethodsWe performed a retrospective multicentre study of all critically ill adult (age ≥ 16 years) patients admitted to Australian intensive care units (ICU) between 1st January 2018 to 31st March 2022. We included all patients who had an IHCA within the 24 h before ICU admission with a documented Clinical Frail Scale (CFS). The primary outcome was median survival up to one year following ICU admission. The effect of frailty on one-year survival was assessed using a Cox proportional hazards model, adjusting for age, sex, comorbidities, sequential organ failure assessment (SOFA) score, and hospital type. ResultsWe examined 3769 patients, of whom 30.8% (n = 1160) were frail (CFS ≥ 5). The median survival was significantly shorter for patients with frailty (median [IQR] days 19 [1–365] vs 302 [9–365]; p < 0.001). The overall one-year mortality was worse for the patients with frailty when compared to the non-frail group (64.8% [95%CI 61.9–67.5] vs 36.4% [95%CI 34.5–38.3], p < 0.001). Each unit increment in the CFS was associated with 22% worse survival outcome (adjusted Hazard ratio = 1.22, 95%-CI 1.19–1.26), after adjustment for confounders. The survival trend was similar among patients who survived the hospitalization. ConclusionIn this retrospective multicentre study, frailty was associated with poorer one-year survival in patients admitted to Australian ICUs following an IHCA.

Intensive care nurses’ perspectives on barriers to oral care practices in non-ventilated patients in adult Australian intensive care units: A qualitative descriptive study

Intensive care nurses’ perspectives on barriers to oral care practices in non-ventilated patients in adult Australian intensive care units: A qualitative descriptive study

Development of a clinical practice guideline for physiotherapy management of adults invasively ventilated with community-acquired pneumonia

Background and settingPatients hospitalised with community-acquired pneumonia (CAP) are frequently admitted to an intensive care unit (ICU) for invasive mechanical ventilation and receive treatment by physiotherapists. However, clinical physiotherapy practice is variable for this ICU cohort. ObjectivesTo develop a clinical practice guideline for physiotherapy management of adults invasively ventilated with CAP using the best available evidence. MethodsGuideline development using evidence synthesis according to the GRADE and JBI approaches, incorporating findings from four preceding phases of a mixed-methods research program: systematic review and meta-analysis, national survey of Australian ICU physiotherapy practice, e-Delphi study to determine expert consensus, and multidisciplinary peer-review of the expert consensus statements by senior ICU clinicians to determine validity and applicability of the statements for translation into practice. ResultsThe guideline comprises 26 recommendations, encompassing physiotherapy assessment, patient selection and prioritisation, and treatment. Physiotherapy treatment covers domains of humidification, patient positioning, hyperinflation techniques, manual chest wall techniques, normal saline instillation, active treatment, and mobilisation. Recommendations are rated as strong or conditional based on JBI criteria, and certainty of evidence according to GRADE. Considerations for practice are provided within the guideline to enhance clarity and practicality, particularly for conditional recommendations where evidence is limited or conflicting. ConclusionThis guideline, based on the best available evidence for clinical physiotherapy practice for adults invasively ventilated with CAP, is intended to support clinicians with clinical decision making. Further research is required to evaluate guideline implementation into clinical practice, and incorporate the values and preferences of ICU patients and their families. Contribution of paper•This world first clinical practice guideline was developed based on the best available evidence for physiotherapy management of adults invasively ventilated with non-COVID-19 community-acquired pneumonia.•The evidence-based guideline provides 26 recommendations across nine domains of physiotherapy assessment and treatment, to guide best practice for this common ICU cohort.

The impact of COVID-19 on the provision of bereavement support in Australian intensive care units: A national survey

BackgroundBereavement support is a vital part of caring for families when a patient dies in the intensive care unit (ICU). Previous research has demonstrated that while many ICUs provide some informal aspects of bereavement care, formalised follow-up programmes are uncommon. The impacts of COVID-19 on ICU-based bereavement support are currently unknown. ObjectivesThe objectives of this study were to explore the current provision of bereavement support in Australian ICUs and identify the impacts of the COVID-19 pandemic on these services. MethodsA cross-sectional exploratory web-based survey was used. The survey was distributed to one senior nurse in each public and private adult, paediatric, and neonatal ICU in Australia between April and July 2022. Descriptive statistics and reflexive thematic analysis were used to analyse the data. Ethical approval was received from La Trobe University. ResultsOne hundred and four ICUs from 82 hospitals responded to the survey, with 36 units reporting a formal bereavement follow-up service. When compared to prepandemic levels, almost all of the common bereavement care practices explored in the survey were significantly reduced during the COVID-19 pandemic. Open-ended responses also demonstrated significant impacts of COVID-19 on bereavement care provision, particularly related to Restricted family togetherness, Logistical Challenges, and Impacts on Staff. Staff members reported adjusting care provision in response to these challenges by exploring Alternative family communications, Facilitation of family togetherness, and Increasing familysupports. ConclusionsMany of the common elements of ICU-based bereavement care were significantly reduced during the COVID-19 pandemic. In addition, the number of formal bereavement follow-up services in Australian ICUs remains largely unchanged since 2015. Ongoing research is needed to explore the long-term effects of these changes on staff and family wellbeing and on ongoing provision of ICU-based bereavement support.

Frailty and long-term survival among patients in Australian intensive care units with metastatic cancer (FRAIL-CANCER study): a retrospective registry-based cohort study

Recent advances in cancer therapeutics have improved outcomes, resulting in increasing candidacy of patients with metastatic cancer being admitted to intensive care units (ICUs). A large proportion of patients also have frailty, predisposing them to poor outcomes, yet the literature reporting on this is scarce. We aimed to assess the impact of frailty on survival in patients with metastatic cancer admitted to the ICU. In this retrospective registry-based cohort study, we used data from the Australia and New Zealand Intensive Care Society Adult Patient (age ≥16 years) database to identify patients with advanced (solid and haematological cancer) and a documented Clinical Frailty scale (CFS) admitted to 166 Australian ICUs. Patients without metastatic cancer were excluded. We analysed the effect of frailty (CFS 5-8) on long-term survival, and how this effect changed in specific subgroups (cancer subtypes, age [<65 years or ≥65 years], and those who survived hospitalisation). Because estimates tend to cluster within centres and vary between them, we used Cox proportional hazards regression models with robust sandwich variance estimators to assess the effect of frailty on survival time up to 4 years after ICU admission between groups. Between Jan 1, 2018, and March 31, 2022, 30 026 patients were eligible, and after exclusions 21 174 patients were included in the analysis; of these, 6806 (32·1%) had frailty, and 11 662 (55·1%) were male, 9489 (44·8%) were female, and 23 (0·1%) were intersex or self-reported indeterminate sex. The overall survival was lower for patients with frailty at 4 years compared with patients without frailty (29·5% vs 10·9%; p<0·0001). Frailty was associated with shorter 4-year survival times (adjusted hazard ratio 1·52 [95% CI 1·43-1·60]), and this effect was seen across all cancer subtypes. Frailty was associated with shorter survival times in patients younger than 65 years (1·66 [1·51-1·83]) and aged 65 years or older (1·40 [1·38-1·56]), but its effects were larger in patients younger than 65 years (pinteraction<0·0001). Frailty was also associated with shorter survival times in patients who survived hospitalisation (1·49 [1·40-1·59]). In patients with metastatic cancer admitted to the ICU, frailty was associated with poorer long-term survival. Patients with frailty might benefit from a goal-concordant time-limited trial in the ICU and will need suitable post-intensive care supportive management. None.

The impact of body mass index on long-term survival after ICU admission due to COVID-19: A retrospective multicentre study

ObjectiveThe impact of obesity on long-term survival after intensive care unit (ICU) admission with severe coronavirus disease 2019 (COVID-19) is unclear. We aimed to quantify the impact of obesity on time to death up to two years in patients admitted to Australian and New Zealand ICUs. DesignRetrospective multicentre study. Setting92 ICUs between 1st January 2020 through to 31st December 2020 in New Zealand and 31st March 2022 in Australia with COVID-19, reported in the Australian and New Zealand Intensive Care Society adult patient database. ParticipantsAll patients with documented height and weight to estimate the body mass index (BMI) were included. Obesity was classified patients according to the World Health Organization recommendations. Interventions and main outcome measuresThe primary outcome was survival time up to two years after ICU admission. The effect of obesity on time to death was assessed using a Cox proportional hazards model. Confounders were acute illness severity, sex, frailty, hospital type and jurisdiction for all patients. ResultsWe examined 2,931 patients; the median BMI was 30.2 (IQR 25.6–36.0) kg/m2. Patients with a BMI ≥30 kg/m2 were younger (median [IQR] age 57.7 [46.2–69.0] vs. 63.0 [50.0–73.6]; p < 0.001) than those with a BMI <30 kg/m2. Most patients (76.6%; 2,244/2,931) were discharged alive after ICU admission. The mortality at two years was highest for BMI categories <18.5 kg/m2 (35.4%) and 18.5–24.9 kg/m2 (31.1%), while lowest for BMI ≥40 kg/m2 (14.5%). After adjusting for confounders and with BMI 18.5–24.9 kg/m2 category as a reference, only the BMI ≥40 kg/m2 category patients had improved survival up to 2 years (hazard ratio = 0.51; 95%CI: 0.34–0.76). ConclusionsThe obesity paradox appears to exist beyond hospital discharge in critically ill patients with COVID-19 admitted in Australian and New Zealand ICUs. A BMI ≥40 kg/m2 was associated with a higher survival time of up to two years.

Long-Term Outcomes of Pulmonary Embolism Requiring Intensive Care Unit (ICU) Admission

Introduction:Pulmonary embolism (PE) requiring intensive care unit (ICU) admission is associated with high in-hospital mortality, however data on long-term survival outcomes and associated contributors remains limited. We sought to further investigate this using a large binational dataset. Methods:Retrospective cohort study of adults aged &amp;gt;16 years admitted to an Australian or New Zealand (NZ) ICU between January 1, 2018 and December 31, 2022 with a primary admission diagnosis of PE using the Australian and NZ Intensive Care Society (ANZICS) Adult Patient Database (APD). Data were available on baseline characteristics - specifically age, gender, admission co-morbidities (active malignancy, chronic cardiovascular, respiratory, renal and liver disease and illness severity as per the Acute Physiology and Chronic Health Evaluation (APACHE) III scoring system. The need for ICU-specific supports (vasopressors or inotropes, invasive and non-invasive ventilation [NIV], extracorporeal membrane oxygenation [ECMO]) was also recorded. All-cause mortality from 30 days to 48 months after ICU admission was obtained. Descriptive analyses, Kaplan-Meier and Cox proportional hazards models were used to describe survival during this time period. Ethical approval was granted by the Alfred Hospital Human Research Ethics Committee (HREC). Results:6447 patients with PE who had been admitted to 193 ICUs across Australia and NZ were identified, representing 9136 patient-years of follow-up. Median age was 66.5 years (interquartile range [IQR], 53-75). 24.5% were admitted to a rural or regional ICU. Median ICU length of stay was 46.6 hours (IQR, 27-79). Median APACHE III score was 42 (IQR, 31-56). Admission co-morbidities included active malignancy (8.1%), chronic respiratory (7.0%), renal (1.4%) and liver (0.4%) disease. Systolic blood pressure was was ≤90 mmHg at time of ICU admission in 1482 patients (23.9% of those in whom this data was available). Vasopressors or inotropes were required in 986 patients (17.6%), NIV was used in 713 (12.6%), invasive ventilation in 453 (8.0%) and 24 patients (0.43%) received ECMO. The mean duration of invasive ventilation where this was required was 14.9 hours. Kaplan-Meier survival analysis is shown in Figure 1. Overall survival was 92.3% at 30 days (95% CI, 91.6-93.0%), 87.5% at 6 months (95% CI, 86.5-88.3%), 84.4% at 12 months (95% CI 83.4%-85.4%) and 73.0% at 48 months (95% CI, 71.0-74.9%). Active malignancy was the strongest independent predictor of mortality (hazard ratio [HR] 3.3, 95% CI 2.8-4.0). Other independent predictors were chronic liver (HR 2.8), renal (HR 1.7) and respiratory (HR 1.6) disease, immunosuppressive therapy (HR 1.5), and the need for NIV (HR 1.4) or vasopressor and inotropic support (HR 1.3). No significant difference in mortality was observed between rural/regional and tertiary/metropolitan ICUs, however improved survival was observed in patients admitted to Australian ICUs (n = 6032) compared to those in NZ (n = 415) (HR 0.5 [95% CI 0.4-0.8]). Conclusions:Nearly three-quarters of patients admitted to ICU due to PE remain alive 2 years later. The largest risk factor for late mortality is malignancy, along with other chronic diseases, which is similar to previous studies reporting long-term follow-up of PE survivors outside ICU, however patients who need advanced life supports (NIV, ECMO) were also at greater risk. Limitations of this study include retrospective design, broad heterogeneity in admission criteria across different ICUs due to variation in resources across both countries and lack of data therapies such as intravenous thrombolysis and anticoagulation. Further work is needed to understand if changes to acute management of at-risk patients might improve long-term survival outcomes.

Agitation during anaesthetic emergence: An observational study of adult cardiac surgery patients in two Australian intensive care units

BackgroundAnaesthetic emergence agitation among adult patients being recovered after open cardiac and/or thoracic aorta surgery has not been described. ObjectivesThe objective of this study was to characterise emergence agitation in terms of incidence, clinical features, and consequences in a cohort of cardiac surgery patients being recovered in the intensive care unit (ICU). MethodsA prospective, observational pilot study was implemented.Over a 5-week period, the study was conducted in two metropolitan hospitals in Victoria, Australia.The cohort comprised all patients admitted to the ICUs aged ≥18 years, who had undergone cardiac surgery via an open sternotomy with general anaesthetic, and whose emergence was directly observed.Emergence agitation was defined as a Richmond Agitation and Sedation Scale score of ≥+2. ResultsFifty patients were observed. Emergence agitation occurred in 24/50 (48%) of patients. Patients with emergence agitation experienced more clinical consequences than patients with calm emergence, including a significantly greater number of episodes of airway compromise (12/24, 50%, p < 0.001); ventilator dyssynchrony (23/24, 96%, p = 0.004); and hypertension (13/24, 54%, p = 0.004). Significant treatment interference (potentially dangerous patient movements such as pulling tubes) occurred with 23/24 patients (96%, p < 0.0001). Patients who underwent emergence agitation required significantly more interventions during anaesthetic emergence than patients who underwent a calm emergence. Interventions included extra nursing measures (16/24, 67%, p = 0.001) administration of sedative and/or opioid intravenous boluses (22/24, 92%, p = 0.001) and vasoactive agents (15/24, 63%, p = 0.05). ConclusionsIn patients recovering from cardiac surgery in the ICU, emergence agitation was clinically important. Immediate interventions were required to prevent and manage complications.

Facilitators and barriers to evidence-based practice in central venous access device insertion and management in an intensive care unit: A qualitative study

IntroductionResearch evidence and clinical practice guidelines exist on preventing central line-associated bloodstream infections. However, there is limited knowledge about the barriers and facilitators to evidence-based central venous access device care. AimThe aim of this study was to investigate the facilitators and barriers to evidence-based central venous access device care in the adult intensive care setting. MethodThis exploratory qualitative study involved focus groups and interviews with registered nurses and physicians involved in central venous access device insertion and management in a tertiary Australian intensive care unit. Purposive sampling was used to recruit staff (n = 26) with varying years of clinical experience and clinical positions. Six focus groups and three individual interviews were conducted. Interviews were audio recorded, transcribed verbatim and analysed using content analysis. ResultsThree overarching categories emerged: work structures to support optimal performance; processes to optimise quality of care, and factors influencing staff members’ behaviour. Perceived facilitators to optimal central venous access device care included explicit language use in procedure documents, work-system integrated strategies, research evidence dissemination, audit, and feedback. However, there was a lack of consistency in practices such as audit, feedback, and patient participation. ConclusionTo bring about effective improvement in central venous access device care, future interventions should be tailored to address identified barriers, including integrating audit and feedback into clinicians’ work processes. Additionally, future research is needed to explore the role of patients and their families in central venous access device care. Implications for clinical practiceWhen developing practice policies or procedure manuals, it is important to use explicit language to ensure clear communication of evidence-based recommendations to clinicians. Strategies integrated into work processes can enhance adherence to evidence-based practice. Large departments with limited educators should explore innovative methods like online education to ensure optimal central venous access device care.

Family presence during resuscitation: Perceptions and confidence of intensive care nurses in an Australian metropolitan hospital

BackgroundWhile literature supporting family presence during resuscitation (FPDR) was first published over three decades ago, the practice remains controversial. Benefits have been confirmed, and barriers to practice identified through international research. The extent that FPDR is practised in Australian intensive care units (ICUs) is currently unknown. ObjectivesTo examine ICU nurses’ previous exposure and experiences with FPDR To establish their perceptions of the risks and benefits of the practice, as well as their confidence participating. MethodsA descriptive, cross-sectional study design, using validated FPDR risk–benefits and confidence scales, was distributed electronically to registered nurses working within a single adult ICU in Australia. ResultsFifty-six percent (n = 45) of respondents had never witnessed FPDR. Respondents were divided on whether families had the right to be present or should be given the option. ICU nurses perceived benefits for families but not for the patients involved or for the nurses participating. Nurses indicated they felt conflicted between the needs of the family, preserving the quality of the care delivered to a deteriorating patient, and protecting the safety of all stakeholders. Support for FPDR was often dependent on the availability of resources such as a family-support person. ConclusionThis research establishes that ICU nurses lacked exposure to FPDR but were confident in their ability to perform, be observed, and support families during a resuscitation event. Therefore, confidence is likely not a factor in a decision to reject the practice. Further education is indicated as there remained a reluctance to adopt FPDR practice, despite many of the barriers reported having already been largely disproven by the available literature. Institutions have a role in policy development, ensuring adequate resources, and education.

Oral challenge vs routine care to assess low-risk penicillin allergy in critically ill hospital patients (ORACLE): a pilot randomised controlled trial

BackgroundSelf-reported penicillin allergies are highly prevalent in hospitalised patients and are associated with poor health and health service outcomes. Critically ill patients have historically been underrepresented in prospective delabelling studies in part due to concerns around clinical stability and reliability of penicillin skin testing. Allergy assessment tools exist to identify low-risk penicillin allergy phenotypes and facilitate direct oral challenge delabelling. PEN-FAST is a clinical decision rule that has been validated to predict true penicillin allergy in a cohort of non-critically ill patients. There is however limited evidence regarding the feasibility, safety and efficacy of direct oral challenges and the use of delabelling clinical decisions rules in the intensive care setting.MethodsCritically ill patients in the intensive care unit (ICU) with low-risk penicillin allergy phenotypes (PEN-FAST score < 3) will be randomised 1:1 to direct oral penicillin challenge (single dose 250 mg oral amoxicillin or implicated penicillin) or routine care, followed by a 2-h observation period. Patients will receive a second oral challenge/observation prior to hospital discharge (with subsequent observation for 2 h). An assessment for antibiotic-associated adverse events will also be undertaken at 24 h and 5 days post each challenge/observation and again at 90 days post-randomisation. The primary outcome measures are feasibility (proportion of eligible patients recruited and protocol compliance) and safety (proportion of patients who experience an antibiotic-associated immune-mediated adverse event or serious adverse event).DiscussionWe will report the feasibility and safety of point-of-care penicillin direct oral challenge in this first randomised controlled trial of low-risk penicillin allergy in critically ill hospitalised patients. Upon completion of the project, important findings will inform the design of planned large prospective multi-centre clinical trials in Australian and international ICUs, further examining safety and efficacy and exploring antimicrobial prescribing-related outcomes following penicillin oral challenge.Trial registrationAustralian New Zealand Clinical Trials RegistryRegistration Number: ACTRN12621000051842Date registered: 20/01/2021https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379735&isReview=true

Understanding an epidemiological view of a retrospective audit of medication errors in an intensive care unit

BackgroundMedication errors in the intensive care setting continue to occur at significant rates and are often associated with adverse events and potentially life-threatening repercussions. Aim/objectiveThe aim of this study was to (i) determine the frequency and severity of medication errors reported in the incident management reporting system; (ii) examine the antecedent events, their nature, the circumstances, risk factors, and contributing factors leading to medication errors; and (iii) identify strategies to improve medication safety in the intensive care unit (ICU). MethodA retrospective, exploratory, descriptive design was selected. Retrospective data were collected from the incident report management system and electronic medical records over a 13-month period from a major metropolitan teaching hospital ICU. ResultsA total of 162 medication errors were reported during a 13-month period, of which, 150 were eligible for inclusion. Most medication errors occurred during the administration (89.4%) and dispensing phases (23.3%). The highest reported errors included incorrect doses (25.3%), incorrect medications (12.7%), omissions (10.7%), and documentation errors (9.3%). Narcotic analgesics (20%), anaesthetics (13.3%), and immunomodifiers (10.7%) were the most frequently reported medication classes associated with medication errors. Prevention strategies were found to be focussed on active errors (67.7%) as opposed to latent errors (32.3%) and included various and infrequent levels of education and follow-up. Active antecedent events included action-based errors (39%) and rule-based errors (29.5%), whereas latent antecedent events were most associated with a breakdown in system safety (39.3%) and education (25%). ConclusionThis study presents an epidemiological view and understanding of medication errors in an Australian ICU. This study highlighted the preventable nature of most medication errors in this study. Improving administration-checking procedures would prevent the occurrence of many medication errors. Approaches aimed at both individual- and organisational-level improvements are recommended to address administration errors and inconsistent medication-checking procedures. Areas for further research include determining the most effective system developments for improving administration-checking procedures and verifying the risk and prevalence of immunomodifier administration errors in the ICU as this is an area not reported previously in the literature. In addition, the impact of single- versus two-person checking procedures on medication errors in the ICU should be prioritised to address current evidence gaps.

Frailty

Frailty in ageing surgical populations worldwide is one of the greatest global health challenges. Currently, 30% of Australian surgical patients are already aged>65 years, with 40,000–50,000 patients with frailty admitted to an Australian intensive care unit (ICU) annually. By 2030, 25% of Australian ICU bed-days will be occupied by patients aged>80 years. Major organisations such as the American Geriatrics Society and the American College of Surgeons strongly recommend perioperative frailty measurement, with clear evidence that this leads to reduced mortality. However, widespread routine systems to measure frailty in surgical patients are lacking. This is despite clear evidence of significantly increased postoperative mortality, new disability, and residential care placement after surgery with frailty.

Nutrition delivery across hospitalisation in critically ill patients with COVID-19: An observational study of the Australian experience

BackgroundData on nutrition delivery over the whole hospital admission in critically ill patients with COVID-19 are scarce, particularly in the Australian setting. ObjectivesThe objective of this study was to describe nutrition delivery in critically ill patients admitted to Australian intensive care units (ICUs) with coronavirus disease 2019 (COVID-19), with a focus on post-ICU nutrition practices. MethodsA multicentre observational study conducted at nine sites included adult patients with a positive COVID-19 diagnosis admitted to the ICU for >24 h and discharged to an acute ward over a 12-month recruitment period from 1 March 2020. Data were extracted on baseline characteristics and clinical outcomes. Nutrition practice data from the ICU and weekly in the post-ICU ward (up to week four) included route of feeding, presence of nutrition-impacting symptoms, and nutrition support received. ResultsA total of 103 patients were included (71% male, age: 58 ± 14 years, body mass index: 30±7 kg/m2), of whom 41.7% (n = 43) received mechanical ventilation within 14 days of ICU admission. While oral nutrition was received by more patients at any time point in the ICU (n = 93, 91.2% of patients) than enteral nutrition (EN) (n = 43, 42.2%) or parenteral nutrition (PN) (n = 2, 2.0%), EN was delivered for a greater duration of time (69.6% feeding days) than oral and PN (29.7% and 0.7%, respectively). More patients received oral intake than the other modes in the post-ICU ward (n = 95, 95.0%), and 40.0% (n = 38/95) of patients were receiving oral nutrition supplements. In the week after ICU discharge, 51.0% of patients (n = 51) had at least one nutrition-impacting symptom, most commonly a reduced appetite (n = 25; 24.5%) or dysphagia (n = 16; 15.7%). ConclusionCritically ill patients during the COVID-19 pandemic in Australia were more likely to receive oral nutrition than artificial nutrition support at any time point both in the ICU and in the post-ICU ward, whereas EN was provided for a greater duration when it was prescribed. Nutrition-impacting symptoms were common.

Mortality among people admitted to Australian intensive care units for reasons other than COVID-19 during the COVID-19 pandemic: a retrospective cohort study.

To investigate in-hospital mortality among people admitted to Australian intensive care units (ICUs) with conditions other than coronavirus disease 2019 (COVID-19) during the COVID-19 pandemic. National, multicentre, retrospective cohort study; analysis of data in the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation (ANZICS CORE) Adult Patient Database. Adults (16 years or older) without COVID-19 admitted to Australian ICUs, 1 January 2016 - 30 June 2022. All-cause in-hospital mortality, unadjusted and relative to the January 2016 value, adjusted for illness severity (Australian and New Zealand Risk of Death [ANZROD] and hospital type), with ICU as a random effect. Points of change in mortality trends (breakpoints) were identified by segmental regression analysis. Data for 950 489 eligible admissions to 186 ICUs were available. In-hospital mortality declined steadily from January 2016 to March 2021 by 0.3% per month (P < 0.001; March 2021 v January 2016: adjusted odds ratio [aOR], 0.70; 95% confidence interval [CI], 0.62-0.80), but rose by 1.4% per month during March 2021 - June2022 (P < 0.001; June 2022 v January 2016: aOR, 1.03; 95% CI, 0.90-1.17). The rise in mortality continued after the number of COVID-19-related ICU admissions had declined; mortality increased in jurisdictions with lower as well as in those with higher numbers of COVID-19-related ICU admissions. The rise in in-hospital mortality among people admitted to Australian ICUs with conditions other than COVID-19 from March 2021 reversed the improvement of the preceding five years. Changes to health service delivery during the pandemic and their consequences should be investigated further.