Intensive Care Society Adult Patient Research Articles

Impact of frailty on long-term survival in patients discharged alive from hospital after an ICU admission with COVID-19

ObjectiveThough frailty is associated with mortality, its impact on long-term survival after an ICU admission with COVID-19 is unclear. We aimed to investigate the association between frailty and long-term survival in patients after an ICU admission with COVID-19. Design, Setting and ParticipantsThis registry-based multicentre, retrospective, cohort study included all patients ≥16 years discharged alive from the hospital following an ICU admission with COVID-19 and documented clinical frailty scale (CFS). Data from 118 ICUs between 01/01/2020 through 31/12/2020 in New Zealand and 31/12/2021 in Australia were reported in the Australian and New Zealand Intensive Care Society Adult Patient Database. The patients were categorised as ‘not frail’ (CFS 1-3), ‘mildly frail’ (CFS 4-5) and ‘moderately-to-severely frail’ (CFS 6-8). Main Outcome MeasuresThe primary outcome was survival time up to two years, which we analysed using Cox regression models. ResultsWe included 4028 patients with COVID-19 in the final analysis. ‘Moderately-to-severely frail’ patients were older (66.6 [56.3–75.8] vs. 69.9 [60.3–78.1]; p < 0.001) than those without frailty (median [interquartile range] 53.0 [40.1–64.6]), had higher sequential organ failure assessment scores (p < 0.001), and less likely to receive mechanical ventilation (p < 0.001) than patients without frailty or mild frailty. After adjusting for confounders, patients with mild frailty (adjusted hazards ratio: 2.31, 95%-CI: 1.75–3.05) and moderate-to-severe frailty (adjusted hazards ratio: 2.54, 95%-CI: 1.89–3.42) had higher mortality rates than those without frailty. ConclusionsFrailty was independently associated with shorter survival times to two years in patients with severe COVID-19 in ANZ following hospital discharge. Recognising frailty provides individualised patient intervention in those with frailty admitted to ICUs with severe COVID-19. Clinical trial registrationNot applicable.

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.

Measuring the Impact of ICU Strain on Mortality, After-Hours Discharge, Discharge Delay, Interhospital Transfer, and Readmission in Australia With the Activity Index.

ICU resource strain leads to adverse patient outcomes. Simple, well-validated measures of ICU strain are lacking. Our objective was to assess whether the "Activity index," an indicator developed during the COVID-19 pandemic, was a valid measure of ICU strain. Retrospective national registry-based cohort study. One hundred seventy-five public and private hospitals in Australia (June 2020 through March 2022). Two hundred seventy-seven thousand seven hundred thirty-seven adult ICU patients. None. Data from the Australian and New Zealand Intensive Care Society Adult Patient Database were matched to the Critical Health Resources Information System. The mean daily Activity index of each ICU (census total of "patients with 1:1 nursing" + "invasive ventilation" + "renal replacement" + "extracorporeal membrane oxygenation" + "active COVID-19," divided by total staffed ICU beds) during the patient's stay in the ICU was calculated. Patients were categorized as being in the ICU during very quiet (Activity index < 0.1), quiet (0.1 to < 0.6), intermediate (0.6 to < 1.1), busy (1.1 to < 1.6), or very busy time-periods (≥ 1.6). The primary outcome was in-hospital mortality. Secondary outcomes included after-hours discharge from the ICU, readmission to the ICU, interhospital transfer to another ICU, and delay in discharge from the ICU. Median Activity index was 0.87 (interquartile range, 0.40-1.24). Nineteen thousand one hundred seventy-seven patients died (6.9%). In-hospital mortality ranged from 2.4% during very quiet to 10.9% during very busy time-periods. After adjusting for confounders, being in an ICU during time-periods with higher Activity indices, was associated with an increased risk of in-hospital mortality (odds ratio [OR], 1.49; 99% CI, 1.38-1.60), after-hours discharge (OR, 1.27; 99% CI, 1.21-1.34), readmission (OR, 1.18; 99% CI, 1.09-1.28), interhospital transfer (OR, 1.92; 99% CI, 1.72-2.15), and less delay in ICU discharge (OR, 0.58; 99% CI, 0.55-0.62): findings consistent with ICU strain. The Activity index is a simple and valid measure that identifies ICUs in which increasing strain leads to progressively worse patient outcomes.

The relationship between nursing skill mix and severity of illness of patients admitted in Australian and New Zealand intensive care units

BackgroundCritically ill patients in the intensive care environment require an appropriate nursing workforce to improve quality of care and patient outcomes. However, limited information exists as to the relationship between severity of illness and nursing skill mix in the intensive care. ObjectiveThe aim of this study was to describe the variation in nursing skill mix across different hospital types and to determine if this was associated with severity of illness of critically ill patients admitted to adult intensive care units (ICUs) in Australia and New Zealand. Design & SettingA retrospective cohort study using the Australia and New Zealand Intensive Care Society Adult Patient Database (to provide information on patient demographics, severity of illness, and outcome) and the Critical Care Resources Registry (to provide information on annual nursing staffing levels and hospital type) from July 2014 to June 2020. Four hospital types (metropolitan, private, rural/regional, and tertiary) and three patient groups (elective surgical, emergency surgical, and medical) were examined. Main outcome measureThe main outcome measure was the proportion of critical care specialist registered nurses (RNs) expressed as a percentage of the full-time equivalent (FTE) of total RNs working within each ICU each year, as reported annually to the Critical Care Resources Registry. ResultsData were examined for 184 ICUs in Australia and New Zealand. During the 6-year study period, 770 747 patients were admitted to these ICUs. Across Australia and New Zealand, the median percentage of registered nursing FTE with a critical care qualification for each ICU (n = 184) was 59.1% (interquartile range [IQR] = 48.9–71.6). The percentage FTE of critical care specialist RNs was highest in private [63.7% (IQR = 52.6–78.2)] and tertiary ICUs [58.1% (IQR = 51.2–70.2)], followed by metropolitan ICUs [56.0% (IQR = 44.5–68.9)] with the lowest in rural/regional hospitals [55.9% (IQR = 44.9–70.0)]. In ICUs with higher percentage FTE of critical care specialist RNs, patients had higher severity of illness, most notably in tertiary and private ICUs. This relationship was persistent across all hospital types when examining subgroups of emergency surgical and medical patients and in multivariable analysis after adjusting for the type of hospital and relative percentage of each diagnostic group. ConclusionsIn Australian and New Zealand ICUs, the highest acuity patients are cared for by nursing teams with the highest percentage FTE of critical care specialist RNs. The Australian and New Zealand healthcare system has a critical care nursing workforce which scales to meet the acuity of ICU patients across Australia and New Zealand.

Projecting Future Climate Impact on National Australian Respiratory-Related Intensive Care Unit Demand.

A robust climate-health projection model has the potential to improve health care resource allocation. We aim to explore the relationship between Australian intensive care unit (ICU) demand and various measures of the long-lived large-scale climate and to develop a future nationwide climate-health projection model. We investigated patients admitted to ICUs in Australia between January 2003 and December 2019 who were exposed to long-lived large-scale combined climatic measures of temperature and humidity. We analysed the projected demand for respiratory-related ICU average length of stay (in days) per capita (ICUD/C) with four historical and one future projection dataset. These datasets included: i) Australian and New Zealand Intensive Care Society adult patient database, ii) Socioeconomic Data and Applications Center gridded global historical population, iii) Australian Bureau of Statistics national historical population, iv) Japanese 55-year Reanalysis historical climate (JRA55), and v) the fifth Coupled Model Inter-comparison Project future climate projections. 148,638 patients with respiratory issues required intensive care between 2003 and 2019. The annual growth in the population density-weighted wet-bulb-globe temperature-a combined measure of temperature and humidity-is strongly correlated with the annual per capita growth ICUD/C for respiratory-related conditions (r=0.771; p<0.001). This relationship was applied to develop a model projecting future respiratory-related ICU demand with three possible future Representative Concentration Pathways (RCP). RCP2.6 (lowest carbon emission climate scenario) showed only a 33.4% increase in Australian ICUD/C demand by 2090, while the RCP8.5 (highest carbon emission climate scenario) demonstrated almost two-fold higher demand (66.1%) than RCP2.6 by2090. The annual growth in population density-weighted wet-bulb-globe temperature correlates with the annual growth in Australian ICUD/C for respiratory-related conditions. A model based on possible future climate scenarios can be developed to predict changes in ICU demand in response to CO2 changes over the coming decades.

The prevalence of post-extubation dysphagia in critically ill adults: an Australian data linkage study

Objective: To define the prevalence of dysphagia after endotracheal intubation in critically ill adult patients. Design: A retrospective observational data linkage cohort study using the Australian and New Zealand Intensive Care Society Adult Patient Database and a mandatory government statewide health care administration database. Setting: Private and public intensive care units (ICUs) within Victoria, Australia. Participants: Adult patients who required endotracheal intubation for the purpose of mechanical ventilation within a Victorian ICU between July 2013 and June 2018. Main outcome measures: Presence of dysphagia, aspiration pneumonia, ICU length of stay, hospital length of stay, and cost per episode of care. Results: Endotracheal intubation in the ICU was required for 71 124 patient episodes across the study period. Dysphagia was coded in 7.3% (n = 5203) of those episodes. Patients with dysphagia required longer ICU (median, 154 [interquartile range (IQR), 78-259] v 53 [IQR, 27-107] hours; P < 0.001) and hospital admissions (median, 20 [IQR, 13-30] v 8 [IQR, 5-15] days; P < 0.001), were more likely to develop aspiration pneumonia (17.2% v 5.6%; odds ratio, 3.0; 95% CI, 2.8-3.2; P < 0.001), and the median health care expenditure increased by 93% per episode of care ($73 586 v $38 108; P < 0.001) compared with patients without dysphagia. Conclusions: Post-extubation dysphagia is associated with adverse patient and health care outcomes. Consideration should be given to strategies that support early identification of patients with dysphagia in the ICU to determine if these adverse outcomes can be reduced.

The impact of language barriers & interpreters on critical care patient outcomes

BackgroundIn a multicultural society, the impact of language proficiency and interpreter use on critical care patient outcomes is unknown. ObjectiveTo investigate the relationship between English language preference, requirement for an interpreter and in-hospital mortality amongst non-elective intensive care unit (ICU) patients. MethodAdult patients admitted to all 23 public ICUs within the state of Victoria, Australia from July 2007 to June 2018, were extracted from The Australian New Zealand Intensive Care Society Adult Patient Database. De-identified patient data was matched using probabilistic methods and statistical linkage keys to the Victorian Admitted Episodes Database. Patients were classified into one of three groups: ‘English preferred’, ‘English not preferred’ and ‘Interpreter required’. Results126,891 ICU admissions were analysed, of whom 3394 (3%) were in the ‘English not preferred’ group and 6355 (5%) in the ‘Interpreter required’ group. Compared to the ‘English preferred’, both the ‘English not preferred’ and ‘Interpreter required’ groups were older, had more co-morbidities and higher severity of illness scores. In-hospital mortality was 13.1% in the ‘English preferred’ group, 19.6% in the ‘English not preferred’ group and 16.7% in the ‘Interpreter required’ group. However, after adjusting for sex, severity of illness and socio-economic status, the ‘English not preferred’ group remained with a higher risk adjusted mortality (OR 1.21, 95%CI 1.07–1.36, P = 0.002), whereas the ‘Interpreter required’ group had a lower adjusted risk of mortality (OR 0.81, 95%CI 0.74–0.89, P < 0.001). ConclusionBeing identified as having a requirement for an interpreter was associated with improved outcomes for adults admitted to public hospital ICUs in Victoria. Interpreter services should be more readily available in the hospital setting. It is recommended that patients, family members and clinicians actively use interpreter services when English is not the preferred language of an ICU patient.

Intensive care admissions following rapid response team reviews in patients with COVID-19 in Australia

Objectives: To evaluate the epidemiology of rapid response team (RRT) reviews that led to intensive care unit (ICU) admissions, and to evaluate the frequency of in-hospital cardiac arrests (IHCAs) among ICU patients with confirmed coronavirus disease 2019 (COVID-19) in Australia. Design: Multicentre, retrospective cohort study. Setting: 48 public and private ICUs in Australia. Participants: All adults (aged ≥ 16 years) with confirmed COVID-19 admitted to participating ICUs between 25 January and 31 October 2020, as part of SPRINT-SARI (Short PeRiod IncideNce sTudy of Severe Acute Respiratory Infection) Australia, which were linked with ICUs contributing to the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD). Main outcome measures and results: Of the 413 critically ill patients with COVID-19 who were analysed, 48.2% (199/413) were admitted from the ward and 30.5% (126/413) were admitted to the ICU following an RRT review. Patients admitted following an RRT review had higher Acute Physiology and Chronic Health Evaluation (APACHE) scores, fewer days from symptom onset to hospitalisation (median, 5.4 [interquartile range (IQR), 3.2-7.6] v 7.1 days [IQR, 4.1-9.8]; P < 0.001) and longer hospitalisations (median, 18 [IQR, 11-33] v 13 days [IQR, 7-24]; P < 0.001) compared with those not admitted via an RRT review. Admissions following RRT review comprised 60.3% (120/199) of all ward-based admissions. Overall, IHCA occurred in 1.9% (8/413) of ICU patients with COVID-19, and most IHCAs (6/8, 75%) occurred during ICU admission. There were no differences in IHCA rates or in ICU or hospital mortality rates based on whether a patient had a prior RRT review or not. Conclusions: This study found that RRT reviews were a common way for deteriorating ward patients with COVID-19 to be admitted to the ICU, and that IHCA was rare among ICU patients with COVID-19.

Comparison of the predictive ability of clinical frailty scale and hospital frailty risk score to determine long-term survival in critically ill patients: a multicentre retrospective cohort study

BackgroundThe Clinical Frailty Scale (CFS) is the most commonly used frailty measure in intensive care unit (ICU) patients. The hospital frailty risk score (HFRS) was recently proposed for the quantification of frailty. We aimed to compare the HFRS with the CFS in critically ill patients in predicting long-term survival up to one year following ICU admission.MethodsIn this retrospective multicentre cohort study from 16 public ICUs in the state of Victoria, Australia between 1st January 2017 and 30th June 2018, ICU admission episodes listed in the Australian and New Zealand Intensive Care Society Adult Patient Database registry with a documented CFS, which had been linked with the Victorian Admitted Episode Dataset and the Victorian Death Index were examined. The HFRS was calculated for each patient using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes that represented pre-existing conditions at the time of index hospital admission. Descriptive methods, Cox proportional hazards and area under the receiver operating characteristic (AUROC) were used to investigate the association between each frailty score and long-term survival up to 1 year, after adjusting for confounders including sex and baseline severity of illness on admission to ICU (Australia New Zealand risk-of-death, ANZROD).Results7001 ICU patients with both frailty measures were analysed. The overall median (IQR) age was 63.7 (49.1–74.0) years; 59.5% (n = 4166) were male; the median (IQR) APACHE II score 14 (10–20). Almost half (46.7%, n = 3266) were mechanically ventilated. The hospital mortality was 9.5% (n = 642) and 1-year mortality was 14.4% (n = 1005). HFRS correlated weakly with CFS (Spearman’s rho 0.13 (95% CI 0.10–0.15) and had a poor agreement (kappa = 0.12, 95% CI 0.10–0.15). Both frailty measures predicted 1-year survival after adjusting for confounders, CFS (HR 1.26, 95% CI 1.21–1.31) and HFRS (HR 1.08, 95% CI 1.02–1.15). The CFS had better discrimination of 1-year mortality than HFRS (AUROC 0.66 vs 0.63 p < 0.0001).ConclusionBoth HFRS and CFS independently predicted up to 1-year survival following an ICU admission with moderate discrimination. The CFS was a better predictor of 1-year survival than the HFRS.

Impact of Nonpharmaceutical Interventions on ICU Admissions During Lockdown for Coronavirus Disease 2019 in New Zealand-A Retrospective Cohort Study.

OBJECTIVES:Nonpharmaceutical interventions are implemented internationally to mitigate the spread of severe acute respiratory syndrome coronavirus 2 with the aim to reduce coronavirus disease 2019–related deaths and to protect the health system, particularly intensive care facilities from being overwhelmed. The aim of this study is to describe the impact of nonpharmaceutical interventions on ICU admissions of non–coronavirus disease 2019–related patients.DESIGN:Retrospective cohort study.SETTING:Analysis of all reported adult patient admissions to New Zealand ICUs during Level 3 and Level 4 lockdown restrictions from March 23, to May 13, 2020, in comparison with equivalent periods from 5 previous years (2015–2019).SUBJECTS:Twelve-thousand one-hundred ninety-two ICU admissions during the time periods of interest were identified.MEASUREMENTS:Patient data were obtained from the Australian and New Zealand Intensive Care Society Adult Patient Database, Australian and New Zealand Intensive Care Society critical care resources registry, and Statistics New Zealand. Study variables included patient baseline characteristics and ICU resource use.MAIN RESULTS:Nonpharmaceutical interventions in New Zealand were associated with a 39.1% decrease in ICU admission rates (p < 0.0001). Both elective (–44.2%) and acute (–36.5%) ICU admissions were significantly reduced when compared with the average of the previous 5 years (both p < 0.0001). ICU occupancy decreased from a mean of 64.3% (2015–2019) to 39.8% in 2020. Case mix, ICU resource use per patient, and ICU and hospital mortality remained unchanged.CONCLUSIONS:The institution of nonpharmaceutical interventions was associated with a significant decrease in elective and acute ICU admissions and ICU resource use. These findings may help hospitals and health authorities planning for surge capacities and elective surgery management in future pandemics.

Infection management processes in intensive care and their association with mortality.

ICU-specific tables of antimicrobial susceptibility for key microbial species ('antibiograms'), antimicrobial stewardship (AMS) programmes and routine rounds by infectious diseases (ID) physicians are processes aimed at improving patient care. Their impact on patient-centred outcomes in Australian and New Zealand ICUs is uncertain. To measure the association of these processes in ICU with in-hospital mortality. The Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database and Critical Care Resources registry were used to extract patient-level factors, ICU-level factors and the year in which each process took place. Descriptive statistics and hierarchical logistic regression were used to determine the relationship between each process and in-hospital mortality. The study included 799 901 adults admitted to 173 ICUs from July 2009 to June 2016. The proportion of patients exposed to each process of care was 38.7% (antibiograms), 77.5% (AMS programmes) and 74.0% (ID rounds). After adjusting for confounders, patients admitted to ICUs that used ICU-specific antibiograms had a lower risk of in-hospital mortality [OR 0.95 (99% CI 0.92-0.99), P = 0.001]. There was no association between the use of AMS programmes [OR 0.98 (99% CI 0.94-1.02), P = 0.16] or routine rounds with ID physicians [OR 0.96 (99% CI 0.09-1.02), P = 0.09] and in-hospital mortality. Use of ICU-specific antibiograms was associated with lower in-hospital mortality for patients admitted to ICU. For hospitals that do not perform ICU-specific antibiograms, their implementation presents a low-risk infection management process that might improve patient outcomes.

Comparison of Intensive Care and Trauma-specific Scoring Systems in Critically Ill Patients

IntroductionAmongst critically ill trauma patients admitted to ICU and still alive and in ICU after 24 hours, it is unclear which trauma scoring system offers the best performance in predicting in-hospital mortality. MethodsThe Australia and New Zealand Intensive Care Society Adult Patient Database and Victorian State Trauma Registry were linked using a unique patient identification number. Six scoring systems were evaluated: the Australian and New Zealand Risk of Death (ANZROD), Acute Physiology and Chronic Health Evaluation III (APACHE III) score and associated APACHE III Risk of Death (ROD), Trauma and Injury Severity Score (TRISS), Injury Severity Score (ISS), New Injury Severity Score (NISS) and the Revised Trauma Score (RTS). Patients who were admitted to ICU for longer than 24 hours were analysed. Performance of each scoring system was assessed primarily by examining the area under the receiver operating characteristic curve (AUROC) and in addition using standardised mortality ratios, Brier score and Hosmer-Lemeshow C statistics where appropriate. Subgroup assessments were made for patients aged 65 years and older, patients between 18 and 40 years of age, major trauma centre and head injury. ResultsOverall, 5,237 major trauma patients who were still alive and in ICU after 24 hours were studied from 25 ICUs in Victoria, Australia between July 2008 and January 2018. Hospital mortality was 10.7%. ANZROD (AUROC 0.91; 95% CI 0.90-0.92), APACHE III ROD (AUROC 0.88; 95% CI 0.87-0.90), and APACHE III (AUROC 0.88; 95% CI 0.87-0.89) were the best performing tools for predicting hospital mortality. TRISS had acceptable overall performance (AUROC 0.78; 95% CI 0.76-0.80) while ISS (AUROC 0.61; 95% CI 0.59-0.64), NISS (AUROC 0.68; 95% CI 0.65-0.70) and RTS (AUROC 0.69; 95% CI 0.67-0.72) performed poorly. The performance of each scoring system was highest in younger adults and poorest in older adults. ConclusionIn ICU patients admitted with a trauma diagnosis and still alive and in ICU after 24 hours, ANZROD and APACHE III had a superior performance when compared with traditional trauma-specific scoring systems in predicting hospital mortality. This was observed both overall and in each of the subgroup analyses. The anatomical scoring systems all performed poorly in the ICU population of Victoria, Australia.

Sex differences in intensive care unit admissions in Australia and New Zealand

Introduction: Fewer women than men are admitted to intensive care units (ICUs) worldwide. Objectives: To quantify the relative contribution of each major diagnostic category to the overall sex balance in ICU admissions in Australia and New Zealand, and to describe changes in the sex balance over time and with patient age. Methods: Retrospective cross-sectional study of Australian and New Zealand ICU admissions recorded in the Australian and New Zealand Intensive Care Society Adult Patient Database between 2005 and 2018. Multivariate logistic regression for the likelihood of female admission considered key explanatory variables: diagnostic category, patient age, admission year, geographic region, hospital type, and planned versus unplanned ICU admission. Results: Overall, 42.3% of 1 616 856 Australian and New Zealand ICU patients were women (99% CI, 42.2–42.4%). 247 988 more men than women were admitted to an ICU during the 14-year study period. There was a sex imbalance in most diagnostic categories: less than 48% women in 15 of 23 diagnostic categories, and greater than 52% women in four diagnostic categories (P &lt; 0.001). Admissions following cardiovascular surgery accounted for over half of the total sex imbalance. The percentage of ICU patients who are women increased linearly from 40.8% in 2005 to 43.6% in 2018 (R2 = 93.1%; P &lt; 0.001). Compared with admission in 2005, the adjusted odds ratio for female admission in 2018 was 1.03 (99% CI, 1.01–1.06). Conclusion: There is a significant sex imbalance in ICU admissions in Australia and New Zealand, widespread across the diagnostic categories. Cardiovascular admissions contribute most to the observed preponderance of men. The proportion of female ICU patients is steadily increasing.

Reduction of in-hospital cardiac arrest rates in intensive care-equipped New South Wales hospitals in association with implementation of Between the Flags rapid response system.

The NSW Clinical Excellence commission introduced the 'Between the Flags' programme, in response to the death of a young patient, as a system-wide approach for early detection and management of the deteriorating patient in all NSW hospitals. The impact of BTF implementation on the 35 larger hospitals with intensive care units (ICU) has not been reported previously. To assess the impact of 'Between the Flags' (BTF), a two-tier rapid response system across 35 hospitals with an ICU in NSW, on the incidence of in-hospital cardiac arrests and the incidence and outcome of patients admitted to an ICU following cardiac arrest and rapid response team activation. This is a prospective observational study of the BTF registry (August 2010 to June 2016) and the Australian and New Zealand Intensive Care Society Adult Patient Database (January 2008 to December 2016) in 35 New South Wales public hospitals with an ICU. The primary outcome studied was the proportion of in-hospital cardiac arrests. Secondary outcomes included changes in the severity of illness and outcomes of cardiac arrest admissions to the ICU and changes in the volume of rapid response calls. The cardiac arrest rate per 1000 hospital admissions declined from 0.91 in the implementation period to 0.70. Propensity score analysis showed significant declines in ICU and hospital mortality and length of stay for cardiac arrest patients admitted to the ICU (all P < 0.001). The BTF programme was associated with a significant reduction in cardiac arrests in hospitals and ICU admissions secondary to cardiac arrests in 35 NSW hospitals with an ICU.

Decreasing Case-Fatality But Not Death Following Admission to ICUs in Australia, 2005-2018

Decreasing Case-Fatality But Not Death Following Admission to ICUs in Australia, 2005-2018

Characteristics and outcomes of patients admitted to regional and rural intensive care units in Australia

Objective: To describe the characteristics and outcomes of patients admitted to regional and rural intensive care units (ICUs). Design, setting and participants: Retrospective database review using the Australian and New Zealand Intensive Care Society Adult Patient Database for admissions between January 2009 and June 2019. Characteristics and outcomes of patients admitted to regional and rural ICUs were compared with metropolitan and tertiary ICUs. Main outcome measures: Primary outcome was hospital mortality. Secondary outcomes included patient characteristics, ICU mortality, ICU and hospital length of stay, need for mechanical ventilation and need for interhospital transfer. Results: Over the sampling period, admissions to regional/rural ICUs averaged nearly 19 000 episodes per annum and comprised 20% of critical care admissions in Australia. Unadjusted mortality was lower, a result that persisted after adjustment for a range of confounders (odds ratio, 0.73; 95% CI, 0.67-0.80; P < 0.01). Admissions are more likely to be emergencies, and patients are more likely to live in areas of relative disadvantage and to require interhospital transfer, but are less likely to require mechanical ventilation. Conclusions: Although illness severity is lower for patients admitted to regional/rural ICUs, hospital mortality after adjustment for a range of confounders is lower. Compared with tertiary ICUs, emergency admissions are more likely, which may have implications for surge capacity during pandemic illness, while mechanical ventilation is less frequently required. Regional/rural ICUs provide care to a substantial proportion of critically ill patients and have a crucial role in the support of regional Australians.

Long term outcomes for Aboriginal and Torres Strait Islander Australians after hospital intensive care.

To assess long term outcomes for Aboriginal and Torres Strait Islander (Indigenous) Australians admitted non-electively to intensive care units (ICUs). Data linkage cohort study; analysis of ICU patient data (Australian and New Zealand Intensive Care Society Adult Patient Database), prospectively collected during 2007-2016. All four university-affiliated level 3 ICUs in South Australia. Mortality (in-hospital, and 12 months and 8 years after admission to ICU), by Indigenous status. 2035 of 39784 non-elective index ICU admissions (5.1%) were of Indigenous Australians, including 1461 of 37661 patients with South Australian residential postcodes. The median age of Indigenous patients (45 years; IQR, 34-57 years) was lower than for non-Indigenous ICU patients (64 years; IQR, 47-76 years). For patients with South Australian postcodes, unadjusted mortality at discharge and 12 months and 8 years after admission was lower for Indigenous patients; after adjusting for age, sex, diabetes, severity of illness, and diagnostic group, mortality was similar for both groups at discharge (adjusted odds ratio [aOR], 0.95; 95% CI, 0.81-1.10), but greater for Indigenous patients at 12 months (aOR, 1.14; 95% CI, 1.03-1.26) and 8 years (adjusted hazard ratio, 1.23; 95% CI, 1.13-1.35). The number of potential years of life lost was greater for Indigenous patients (median, 24.0; IQR, 15.8-31.8 v 12.5; IQR, 0-22.3), but, referenced to respective population life expectancies, relative survival at 8 years was similar (proportions: Indigenous, 0.78; 95% CI, 0.75-0.80; non-Indigenous, 0.77; 95% CI, 0.76-0.78). Adjusted long term mortality and median number of potential life years lost are higher for Indigenous than non-Indigenous patients after intensive care in hospital. These differences reflect underlying population survival patterns rather than the effects of ICU admission.

The Association between Discharge Delay from Intensive Care and Patient Outcomes.

Rationale: ICU discharge delay occurs when a patient is considered ready to be discharged but remains in the ICU. The effect of discharge delay on patient outcomes is uncertain.Objectives: To investigate the association between discharge delay and patient outcomes including hospital mortality, readmission to ICU, and length of hospital stay after ICU discharge.Methods: Data were accessed from the Australian and New Zealand Intensive Care Society Adult Patient Database between 2011 and 2019. Descriptive analyses and hierarchical logistic and Cox proportional hazards regression were used to examine association between discharge delay and adjusted outcomes. Patients were stratified and analyzed by categories of mortality risk at ICU admission.Measurements and Main Results: The study included 1,014,540 patients from 190 ICUs: 756,131 (75%) were discharged within 6 hours of being deemed ready, with 137,042 (13%) discharged in the next 6 hours; 17,656 (2%) were delayed 48-72 hours; 31,389 (3.1%) died in hospital; and 45,899 (4.5%) patients were readmitted to ICU. Risk-adjusted mortality declined with increasing discharge delay and was lowest at 48-72 hours (adjusted odds ratio, 0.87; 95% confidence interval, 0.79-0.94). The effect was seen in patients with predicted risk of death on admission to ICU of greater than 5% (adjusted odds ratio, 0.77; 95% confidence interval, 0.70-0.84). There was a progressive reduction in adjusted odds of readmission with increasing discharge delay.Conclusions: Increasing discharge delay in ICUs is associated with reduced likelihood of mortality and ICU readmission in high-risk patients. Consideration should be given to delay the discharge of patients with high risk of death on ICU admission.

Impact of language barriers and interpreter requirement on non-elective intensive care patient outcomes

Background: In a multicultural society, limited data is available on the impact of language proficiency and utilisation of interpreters on critical care patient outcomes. Objective To investigate the relationship between hospital outcomes of non-elective intensive care unit (ICU) patients with language barriers and interpreter requirement. Methodology: Patients admitted to 23 adult public ICUs within the state of Victoria, Australia from July 2007 to June 2018, were extracted from The Australian New Zealand Intensive Care Society Adult Patient Database. De-identified patient data was matched using probabilistic methods and statistical linkage keys to the Victorian Admitted Episodes Database. Patients were classified into one of three groups; English as preferred language (EPL), English not-preferred language (ENPL), and English not-preferred language, interpreter required (ENPL-IR). Results: ICU admissions (n=126,891) were analysed of whom 6,355 (5%) were in the ENPL-IR group and 3,394 (3%) in the ENPL group. Compared to EPL, both groups of ENPL were older, had more co-morbidities and higher severity of illness scores. In-hospital mortality was 13.1% in EPL, 16.7% in the ENPL-IR group and 19.6% in the ENPL group. However, after adjusting for age, severity of illness and socio-economic status, the ENPL group remained with a higher risk adjusted mortality (OR 1.21, 95%CI 1.07-1.36, P = 0.002), whereas ENPL-IR group had a lower risk adjusted mortality (OR 0.81, 95%CI 0.74-0.89, P<0.001). Conclusion: The requirement for an interpreter is strongly associated with improved hospital outcomes for non-elective ICU patients with English as a non-preferred language. In view of these results, it is recommended that patients, family members and clinicians utilise interpreter services when English is not the preferred language of an ICU patient.

Characteristics and outcomes of patients with acute liver failure admitted to Australian and New Zealand intensive care units.

Knowledge about patients with acute liver failure (ALF) in Australia and New Zealand (ANZ) is lacking. To evaluate whether the pattern of ALF would be similar to previous studies and whether, despite potentially low transplantation rates, mortality would be comparable. We obtained data from the ANZ Intensive Care Society Adult Patient Database and the ANZ Liver Transplant Registry for 10 years commencing 2005 and analysed for patient outcomes. During the study period, 1 022 698 adults were admitted to intensive care units across ANZ, of which 723 had ALF. The estimated annual incidence of ALF over this period was 3.4/million people and increased over time (P = 0.001). ALF patients had high illness severity (Acute Physiology And Chronic Health Evaluation III 79.8 vs 50.1 in non-ALF patients; P < 0.0001) and were more likely to be younger, female, pregnant and immunosuppressed. ALF was an independent predictor of mortality (odds ratio 1.5 (1.26-1.79); P < 0.0001). At less than 23%, the use of liver transplantation was low, but the mortality of 39% was similar to previous studies. ALF is a rare but increasing diagnosis in ANZ intensive care units. Low transplantation rates in ANZ for ALF do not appear to be associated with higher mortality rates than reported in the literature.