Australian Intensive Care Unit Research Articles

Quality of practice in an intensive care unit (ICU): A mini-ethnographic case study

Nurses' perspectives of maintaining quality practice is important in the context of today's safety and quality agenda. This study provides a snapshot of registered nurses' perspectives on practice quality in one Australian ICU. A mini-ethnographic case study examined how quality is embedded in the culture of ICU nursing. Semi-structured interviews of 10 informants were analysed using Spradley's (Spradley JP. The ethnographic interview. Sydney: Holt, Rinehart and Winston, Inc.;1979) ethnographic guidelines. Three major themes influenced nursing quality: maintaining cohesiveness in a complex and stressful environment; rapid, effective and respectful communication; and specialist knowledge gained through experience and formal learning. The nurses reported satisfaction with the quality of their ICU practice, but revealed factors that could diminish quality and contribute to job dissatisfaction. Given current recruitment and retention issues and the link between satisfaction and retention, it is important to consider this these factors in advancing the knowledge base for workforce planning.

Results of the arouse study: Exploring daily sedation interruption in Australian intensive care units – an anzics clinical trials group endorsed study

Results of the arouse study: Exploring daily sedation interruption in Australian intensive care units – an anzics clinical trials group endorsed study

Sedation management in an Australian intensive care unit: An exploratory study of nurses’ and doctors’ practices and opinions

ractice. To achieve this goal we launched a multiaceted Integration of Nursing Research, Education nd Practice (IN-REP) program that involved the evelopment of evidence-based practice leaders s a way of fostering evidence-based approaches o patient care. The development of three flagship vidence-based practice wards was central to this nitiative. The first project was the introduction f single checking and administrating medications SCAM). Using strategies reported in the research interation literature, we developed a program that acilitated developing skills in clinical leadership, hange management, research integration and vidence-based practice. Additionally, evidenceased practice leaders were actively involved in the evelopment of educationmaterials and implemenation strategies. Prior to implementing the SCAM rogram we pre-tested nurses’ attitudes to single hecking and repeated this survey post implemenation. We also evaluated nurses’ perceptions of the N-REP program. The preand post-test results showed a signifiant improvement for 11 of the 12 items including: ime saving where 65% agreed in the pre-test and 8% in the post-test; confidence with single checkng skills where 13% agreed in the pre-test and 98% n the post-test. Furthermore, the pre-test showed 6.4% of respondents were in favor of single checkng and post-test 78%. This nursing-led initiative offered a structured ay to implement change, develop evidenceased practice and a culture of inquiry. IN-REP ombined the expertise of skilled clinicians with he expertise of academics and skilled researhers.

Adaption and validation of the quality in Intensive Care Patient Care Scale (QICPaCS)

The ability to quantify improvements in care in response to practice improvement initiatives is dependent on an effective measurement instrument. We sought to develop and test the Quality in Intensive Care Patient Care Scale (QICPaCS) that was formed through the combination of the Quality Patient Care Scale, the Australian College of Critical Care Nurses Competency Standards and the Critical Care Family Needs Inventory. This two-phase study assessed the content validity, inter-rater reliability and construct validity of the QICPaCS in an Australian Intensive Care Unit (ICU). An expert panel of nine critical care nurses assessed content validity by rating each domain and item for relevance, clarity and representativeness. Three experienced critical care nurses observed 100 episodes of care in a tertiary referral ICU. Inter-rater reliability was assessed through dual measurement of 20 episodes of care. Construct validity was assessed using exploratory factor analysis, with alpha reliabilities determined for each factor. Content validity was rated high with an average agreement of 97% for relevance, 97% for clarity and 94% for representativeness. Inter-rater reliability was high (kappa 0.82). A three factor model incorporating ten items explained >60% of the variance in quality of care provided. Factors included informed nursing care, moral and ethical care and communication. The content validity and inter-rater reliability of the QICPaCS were demonstrated to be high in this study. Although this exploratory model is parsimonious, given that only ten items contributed to measurement of quality of care, further investigation to identify more complete description of the construct is necessary.

Determinants of mortality in non-neutropenic ICU patients with candidaemia

IntroductionCandidaemia in critically-ill intensive care unit (ICU) patients is associated with high crude mortality. Determinants of mortality – particularly those amenable to potential modification – are incompletely defined.MethodsA nationwide prospective clinical and microbiological cohort study of all episodes of ICU-acquired candidaemia occurring in non-neutropenic adults was undertaken in Australian ICUs between 2001 and 2004. Multivariate Cox regression analyses were performed to determine independently significant variables associated with mortality.Results183 episodes of ICU-acquired candidaemia occurred in 183 patients during the study period. Of the 179 with microbiological data, Candida albicans accounted for 111 (62%) episodes and Candida glabrata, 32 (18%). Outcome data were available for 173: crude hospital mortality at 30 days was 56%. Host factors (older age, ICU admission diagnosis, mechanical ventilation and ICU admission diagnosis) and failure to receive systemic antifungal therapy were significantly associated with mortality on multivariate analysis. Among the subset who received initial fluconazole therapy (n = 93), the crude mortality was 52%. Host factors (increasing age and haemodialysis receipt), but not organism- (Candida species, fluconazole MIC), pharmacokinetic- (fluconazole dose, time to initiation), or pharmacodynamic-related parameters (fluconazole dose:MIC ratio) were associated with mortality. Process of care measures advocated in recent guidelines were implemented inconsistently: follow-up blood cultures were obtained in 68% of patients, central venous catheters removed within five days in 80% and ophthalmological examination performed in 36%.ConclusionsCrude mortality remains high in Australian ICU patients with candidaemia and is overwhelmingly related to host factors but not treatment variables (the time to initiation of antifungals or fluconazole pharmacokinetic and pharmacodynamic factors). The role and timing of early antifungal intervention in critically-ill ICU patients requires further investigation.

A randomized trial of protocol-directed sedation management for mechanical ventilation in an Australian intensive care unit

A randomized trial of protocol-directed sedation management for mechanical ventilation in an Australian intensive care unit

The International Nosocomial Infection Control Consortium (INICC): Goals and objectives, description of surveillance methods, and operational activities

We have shown that intensive care units (ICUs) in countries with limited resources have rates of device-associated health care-associated infection (HAI), including central line-related bloodstream infection (CLAB), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infection (CAUTI), 3 to 5 times higher than rates reported from North American, Western European, and Australian ICUs. The International Nosocomial Infection Control Consortium (INICC) is an international ongoing collaborative HAI control program with a surveillance system based on that of the US National Healthcare Safety Network. The INICC was founded 10 years ago to promote evidence-based infection control in hospitals in limited-resource countries and in hospitals of developed countries without sufficient experience in HAI surveillance and control, through the analysis and feedback of surveillance data collected voluntarily by the member hospitals. It developed from a handful of South American hospitals in 1998 to a dynamic network of 98 ICUs in 18 countries, and is the only source of aggregate standardized international data on HAI epidemiology. Herein we report the criteria and mechanisms for gaining membership in INICC; the training of personnel in INICC hospitals; the INICC protocol for outcome surveillance of CLABs, VAPs, and CAUTIs in ICUs, microorganism profiles, bacterial resistance, antibiotic use, extra length of stay, extra costs, extra mortality, and risk factor analysis, and for process surveillance, including compliance rates for hand hygiene, vascular catheter care, urinary catheter care, and measures for prevention of VAP; and the use of surveillance data feedback as a powerful weapon for control of HAIs. The INICC will continue to evolve in its quest to find more effective and efficient ways to assess patient risk and improve patient safety in hospitals.

Implementation of a multimodal infection control program during an Acinetobacter outbreak

Acinetobacter in the ICU presents a challenge worldwide due to its capacity for long-term survival on environmental surfaces. This report describes a multimodal infection control program designed to control a sustained outbreak Acinetobacter colonization. Multimodal interventions implemented by unit-appointed infection control nurses in an Australian intensive care unit (ICU) during a sustained outbreak of Acinetobacter colonization. In the first 12 months of the outbreak, the mean monthly colonization rate was 3.1 (+/-1.2) cases per 100 bed-days (increased from 0.5 [+/-0.4] in the previous 6 months). In the subsequent 20-months, the mean monthly colonization rates declined to 1.5 (+/-1.5) cases per 100 bed-days (P=0.004). Hand hygiene compliance increased from 33% (95% CI 30-36%) before action plan implementation to 49% (95% CI 46-52%) measured 6-months after implementation. Compliance subsequently dropped to 39% (95% CI 36-42%) 12-months after implementation. The median volume of alcohol/chlorhexidine hand rub solution used per 1000 bed-days increased from 24L (interquartile range (IQR) 12-47L) to 148L (IQR 120-165L) per 1000 bed-days (P<0.001). Introduction of ICU-appointed infection control nurses, who then led multimodal interventions, was effective in reducing the rate of Acinetobacter colonization.

Duration of Mechanical Ventilation in an Adult Intensive Care Unit After Introduction of Sedation and Pain Scales

Sedation and analgesia scales promote a less-distressing experience in the intensive care unit and minimize complications for patients receiving mechanical ventilation. To evaluate outcomes before and after introduction of scales for sedation and analgesia in a general intensive care unit. A before-and-after design was used to evaluate introduction of the Richmond Agitation-Sedation Scale and the Behavioral Pain Scale for patients receiving mechanical ventilation. Data were collected for 6 months before and 6 months after training in and introduction of the scales. A total of 769 patients received mechanical ventilation for at least 6 hours (369 patients before and 400 patients after implementation). Age, scores on the Acute Physiology and Chronic Health Evaluation (APACHE) II, and diagnostic groups were similar in the 2 groups, but the after group had more men than did the before group. Duration of mechanical ventilation did not change significantly after the scales were introduced (median, 24 vs 28 hours). For patients who received mechanical ventilation for 96 hours or longer (24%), mechanical ventilation lasted longer after implementation of the scales (P=.03). Length of stay in the intensive care unit was similar in the 2 groups (P= .18), but patients received sedatives for longer after implementation (P=.01). By logistic regression analysis, APACHE II score (P<.001) and diagnostic group (P<.001) were independent predictors of mechanical ventilation lasting 96 hours or longer. Sedation and analgesia scales did not reduce duration of ventilation in an Australian intensive care unit.

A randomised, controlled trial of conventional versus automated weaning from mechanical ventilation using SmartCare™/PS

Preliminary assessment of an automated weaning system (SmartCare/PS) compared to usual management of weaning from mechanical ventilation performed in the absence of formal protocols. A randomised, controlled pilot study in one Australian intensive care unit. A total of 102 patients were equally divided between SmartCare/PS and Control. The automated system titrated pressure support, conducted a spontaneous breathing trial and provided notification of success ("separation potential"). The median time from the first identified point of suitability for weaning commencement to the state of "separation potential" using SmartCare/PS was 20 h (interquartile range, IQR, 2-40) compared to 8 h (IQR 2-43) with Control (log-rank P = 0.3). The median time to successful extubation was 43 h (IQR 6-169) using SmartCare/PS and 40 (14-87) with Control (log-rank P = 0.6). Unadjusted, the estimated probability of reaching "separation potential" was 21% lower (95% CI, 48% lower to 20% greater) with SmartCare/PS compared to Control. Adjusted for other covariates (age, gender, APACHE II, SOFAmax, neuromuscular blockade, corticosteroids, coma and elevated blood glucose), these estimates were 31% lower (95% CI, 56% lower to 9% greater) with SmartCare/PS. The study groups showed comparable rates of reintubation, non-invasive ventilation post-extubation, tracheostomy, sedation, neuromuscular blockade and use of corticosteroids. Substantial reductions in weaning duration previously demonstrated were not confirmed when the SmartCare/PS system was compared to weaning managed by experienced critical care specialty nurses, using a 1:1 nurse-to-patient ratio. The effect of SmartCare/PS may be influenced by the local clinical organisational context. 28. Mechanical ventilation: weaning.

Management of central venous catheters in adult intensive care units in Australia: policies and practices

The aim of this study was to describe current practice for insertion and care of central venous catheters (CVCs) in intensive care units (ICUs) in Australia and to compare current practice with international guidelines. A prospective telephone survey was conducted to gather data that describe existing practices. A multivariate analysis of the data was conducted using clustering techniques. In the context of this study, cluster analysis was used to find groups with similar approaches to CVC practices. Forty Australian hospitals with level 2 or 3 ICUs as defined by ANZICS were randomly selected and four ICU nurses from each were randomly selected for interview. A total of 34 ICUs and 133 ICU nurses agreed to participate. All states and territories were represented. The majority of CVC management practices in Australian ICUs are consistent with the latest Centers for Disease Control and Prevention (CDC) guidelines. However, practices that did not comply with the recommendations included maximal sterile barrier precautions such as use of cap and mask, choice of dressing, catheter insertion site, cleansing of CVC port before CVC access, replacement of administration sets and CVCs, removal of CVCs and the choice of liquid soap over antiseptic containing soap. The heterogeneity of practice observed and the divergence from the CDC guidelines suggests that practices for insertion and care of CVCs in ICUs in Australia can be improved. Improved practice may result in lower rates of catheter-related bloodstream infection, save costs and improve health outcomes.

A randomized trial of protocol-directed sedation management for mechanical ventilation in an Australian intensive care unit*

To compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients. Randomized, controlled trial. General intensive care unit (24 beds) in an Australian metropolitan teaching hospital. Adult, mechanically ventilated patients (n = 312). Patients were randomly assigned to receive sedation directed by formal guidelines (protocol group, n = 153) or usual local clinical practice (control, n = 159). The median (95% confidence interval) duration of ventilation was 79 hrs (56-93 hrs) for patients in the protocol group compared with 58 hrs (44-78 hrs) for patients who received control care (p = .20). Lengths of stay (median [range]) in the intensive care unit (94 [2-1106] hrs vs. 88 (14-962) hrs, p = .58) and hospital (13 [1-113] days vs. 13 (1-365) days, p = .97) were similar, as were the proportions of subjects receiving a tracheostomy (17% vs. 15%, p = .64) or undergoing unplanned self-extubation (1.3% vs. 0.6%, p = .61). Death in the intensive care unit occurred in 32 (21%) patients in the protocol group and 32 (20%) control subjects (p = .89), with a similar overall proportion of deaths in hospital (25% vs. 22%, p = .51). A Cox proportional hazards model, after adjustment for age, gender, Acute Physiology and Chronic Health Evaluation II score, diagnostic category, and doses of commonly used drugs, estimated that protocol sedation management was associated with a 22% decrease (95% confidence interval 40% decrease to 2% increase, p = .07) in the occurrence of successful weaning from mechanical ventilation. This randomized trial provided no evidence of a substantial reduction in the duration of mechanical ventilation or length of stay, in either the intensive care unit or the hospital, with the use of protocol-directed sedation compared with usual local management. Qualified high-intensity nurse staffing and routine Australian intensive care unit nursing responsibility for many aspects of ventilatory practice may explain the contrast between these findings and some recent North American studies.

Rehabilitation and exercise prescription in Australian intensive care units

Objectives To identify methods of exercise prescription by physiotherapists across Australian intensive care units (ICUs), including the most commonly used activities for both mechanically ventilated and spontaneously breathing patients; and to determine the outcome measures used for the evaluation of exercise intervention. Design Postal questionnaire. Setting One hundred and sixty-seven adult ICUs across all Australian states and territories. Participants Australian intensive care physiotherapists. Results In total, 126 questionnaires were returned from all states and territories of Australia except the Northern Territory. Almost half of the ICUs (49%, 20/41) that did not return a questionnaire lacked a permanent physiotherapy service. Seventy-eight percent (87/111) of respondents were senior staff, and 49% (54/111) of respondents had worked in ICUs for longer than 5 years. Almost all (94%, 104/111) physiotherapists prescribed exercise routinely for ICU patients, with active and active-assisted exercise techniques along with mobilisation being the most common activities utilised. Heart rate, oxygen saturation and respiratory rate were the most important factors used in modification of exercise prescription. Seventy-one percent (79/111) of respondents prescribed exercise routinely for mechanically ventilated patients, but altered the type of exercise prescription for these patients compared with spontaneously breathing patients. Only one-third (34%, 38/111) of physiotherapists used outcome measures routinely in ICU exercise prescription. Conclusions Although a large majority of ICU physiotherapists prescribed exercise routinely in ICU patients (including those on mechanical ventilation), practice varies widely throughout Australia. No validated, functional exercise outcome measures were used, highlighting that further research is required to enable adequate evaluation of exercise prescription and rehabilitation in ICUs.

End-of-life decisions in Austria's intensive care units

Intensive care physicians are often confronted with decisions to withhold or withdraw life-sustaining care in critically ill patients. Such decisions have become more frequent during the past decade and currently are involved in the majority of deaths in intensive care units (ICUs) in Western countries [1]. In most of these cases the patients are incompetent, but physicians and families usually agree to limit care. Moreover, critical care providers face difficult decisions about how to allocate limited resources to patients with competing needs. Most ICU physicians refuse to make choices based on estimates of who might benefit most [2]. Certainly, this aspect must become a major issue for discussion within intensive care medicine and for legislation in the near future. As in other European countries, end-of-life care decisions and the use of critical care resources in Austria are taking place within a legal framework which is poorly adapted to these special situations and the demands of modern medicine. Currently, there are few circumstances in which current legislation really supports the physician in decision making at the bedside. Thus, a growing number of countries have tried to modify legislation to better meet the needs of modern critical care medicine (see, for example, [3, 4]). Limitation of life-sustaining therapy in Austrian ICUs

Mortality and length-of-stay outcomes, 1993–2003, in the binational Australian and New Zealand intensive care adult patient database*

Intensive care unit (ICU) outcomes have been the subject of controversy. The objective was to model hospital mortality and ICU length-of-stay time-change of patients recorded in the Australian and New Zealand Intensive Care Society adult patient database. Retrospective, cohort study of prospectively collected data on index patient admissions. Australian and New Zealand ICUs, 1993-2003. The Australian and New Zealand Intensive Care Society adult patient database, which contains data for 223,129 patients. None. Hospital mortality and ICU length of stay were modeled using logistic and linear regression, respectively, with determination (80%) and validation (20%) data sets. Model adequacy was assessed by discrimination (receiver operating characteristic curve area, AZ) and calibration (Hosmer-Lemeshow C) for mortality and R2 for length of stay. Predictor variables included patient demographics, severity score, surgical and ventilation status, ICU categories, and geographical locality. The data set comprised 223,129 patients: Their mean (SD) age was 59.2 (18.9) yrs, 41.7% were female, their mean (SD) Acute Physiology and Chronic Health Evaluation (APACHE) III score was 53 (31), they had 16.1% overall mortality rate, and 45.7% were mechanically ventilated. ICU length of stay was 3.6 (5.6) days. A(Z), C statistic, and R2 for developmental and validation model data sets were 0.88, 17.64 (p = .02), and 0.18; and 0.88, 12.32 (p = .26), and 0.18, respectively. Variables with mortality impact (p < or = .001) were age (odds ratio [OR] 1.023), gender (OR 1.16; males vs. females), APACHE III score (OR 1.06), mechanical ventilation (OR 1.66), and surgical status (elective, OR 0.17; emergency, OR 0.47; compared with nonsurgical). ICU level and locality had significant mortality-time effects. Similar variables were found to predict length of stay. Risk-adjusted mortality declined, during 1993-2003, from 0.19 (95% confidence interval 0.17-0.21) to 0.15 (0.13-0.16) and similarly for ventilated patients: 0.26 (0.24-0.29) to 0.23 (0.21-0.25). Predicted mean ICU length of stay (days) demonstrated minimal overall time-change: 3.4 (2.2) in 1993 to 3.5 (2.7) in 2003, peaking at 3.7 (2.4) in 2000. Overall hospital mortality rate in patients admitted to Australian and New Zealand ICUs decreased 4% over 11 yrs. A similar trend occurred for mechanically ventilated patients. Length of stay changed minimally over this period.

Mortality and Morbidities Among Very Premature Infants Admitted After Hours in an Australian Neonatal Intensive Care Unit Network

Mortality and Morbidities Among Very Premature Infants Admitted After Hours in an Australian Neonatal Intensive Care Unit Network

Decisions Made By Critical Care Nurses During Mechanical Ventilation and Weaning in an Australian Intensive Care Unit

Responsibilities of critical care nurses for management of mechanical ventilation may differ among countries. Organizational interventions, including weaning protocols, may have a variable impact in settings that differ in nursing autonomy and interdisciplinary collaboration. To characterize the role of Australian critical care nurses in the management of mechanical ventilation. A 3-month, prospective cohort study was performed. All clinical decisions related to mechanical ventilation in a 24-bed, combined medical-surgical adult intensive care unit at the Royal Melbourne Hospital, a university-affiliated teaching hospital in Melbourne, Victoria, Australia, were determined. Of 474 patients admitted during the 81-day study period, 319 (67%) received mechanical ventilation. Death occurred in 12.5% (40/319) of patients. Median durations of mechanical ventilation and intensive care stay were 0.9 and 1.9 days, respectively. A total of 3986 ventilation and weaning decisions (defined as any adjustment to ventilator settings, including mode change; rate or pressure support adjustment; and titration of tidal volume, positive end-expiratory pressure, or fraction of inspired oxygen) were made. Of these, 2538 decisions (64%) were made by nurses alone, 693 (17%) by medical staff, and 755 (19%) by nurses and staff in collaboration. Decisions made exclusively by nurses were less common for patients with predominantly respiratory disease or multiple organ dysfunction than for other patients. In this unit, critical care nurses have high levels of responsibility for, and autonomy in, the management of mechanical ventilation and weaning. Revalidation of protocols for ventilation practices in other clinical contexts may be needed.

Examining the Occurrence of Adverse Events within 72 hours of Discharge from the Intensive Care Unit

Adverse events have negative consequences for patients, including increased risk of death or permanent disability. Reports describe suboptimal patient care on hospital wards and reasons for re-admission to the intensive care unit (ICU) but limited data exists on the occurrence of adverse events, their characteristics and outcomes in patients recently discharged from the ICU to the ward. This prospective observational study describes the incidence and outcomes of adverse events within 72 hours of discharge from an Australian ICU over 12 weeks in 2006. Patients were excluded if they were admitted to ICU after booked surgery or uncomplicated drug overdose, were discharged from ICU to the high dependency unit or had a 'do-not-resuscitate' order Clinical antecedents and preventability were determined for each event. Seventeen (10%) of the 167 discharges that met the inclusion criteria were associated with an adverse event, with nine (52%) judged as probably preventable. Seven adverse events occurred from discharges between 1700 and 0700 hours and seven were on weekends. The most common adverse events were related to fluid management (47%). Outcomes included three ICU readmissions, two high dependency unit admissions and two required one-to-one ward nursing. Two adverse events resulted in temporary disability, seven resulted in prolonged hospital stays and two were associated with death. Delay in taking action for abnormal physiological signs and infrequent charting were evident. Whilst the adverse event rate compared favourably with other reports, 64% of the events were considered preventable. A review of support systems and processes is recommended to better target transition from the ICU.

Why is there such a difference in outcome between Australian intensive care units and others?

The aim of this article is to assess the data on clinical outcomes for critically ill patients admitted to Australian and New Zealand intensive care units in comparison to information available for similar patients in other counties Australia and New Zealand have been collecting standardized data intensive care unit admissions for over a decade. The Australian and New Zealand Intensive Care Society Database Management Committee has developed a high quality database of close to 600 000 adult intensive care unit admissions. Although comparisons suffer from significant methodological, case-mix and process differences, which make their findings easily subject to criticism, interrogation of this database and of data from clusters of intensive care units within this system consistently yields patient outcomes, which are better than outcomes reported from other nations or international studies for similar patients. In addition, Australia and New Zealand has now achieved the highest rate of patient enrollment in an investigator-initiated multicentre randomized controlled trials. Although comparisons in outcome between Australia and New Zealand intensive care units and other units worldwide may not have sufficient scientific rigour to truly reflect better national outcomes, many features of Australian and New Zealand units are unique and worthy of consideration by other national systems as they consider their strategic national goals for the next decade.

Dialysis in Intensive Care Unit Patients with Acute Kidney Injury

When comparing continuous renal replacement therapy (CRRT) with intermittent therapy, it is wise to remember that the very reason for the development and introduction of CRRT into clinical practice in the late 1970s and early 1980s was to compensate for the clear inadequacies of conventional intermittent hemodialysis (IHD) in the treatment of critically ill patients with multi-organ failure (1). If there had not been serious problems with conventional IHD, CRRT would not be the subject for discussion. In the ensuing 10 to 15 yr, substantial clinical experience accumulated in the use of CRRT, and its technology evolved a great deal from adaptive arteriovenous techniques to dedicated CRRT machines for venovenous therapy. During this period, multiple studies confirmed the many physiological advantages of CRRT over conventional IHD (3 to 4 h/d every second day as typically delivered to end-stage renal failure patients) (2–7). This was especially true in centers that had developed appropriate and necessary physician and nursing expertise in its application. Importantly and predictably, not a single comparative study showed IHD to be physiologically better than CRRT—ever. In response to such evidence, over the last two decades physicians and nurses worldwide have literally “voted with their feet” in many countries by increasingly shifting from conventional IHD to CRRT (8). In fact, conventional IHD has essentially disappeared from the Australian intensive care unit (ICU) (9). However, the controversy as to which therapy is “best” from the point of view of mortality or other major clinical outcomes (duration of ICU stay, hospital stay, and rate and time to renal recovery) remains. This is because no sufficiently powered, multicenter, randomized controlled trials have yet been conducted to assess these outcomes and because there have been major and continuing changes in what experts consider optimal continuous therapy or optimal intermittent therapy. So …