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

OBJECTIVE: 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. DESIGN: 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. SETTING, PARTICIPANTS: Adults (16 years or older) without COVID-19 admitted to Australian ICUs, 1 January 2016 - 30 June 2022. MAIN OUTCOME MEASURES: 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. RESULTS: 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 - June 2022 (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. CONCLUSION: 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.

The risk of postoperative deterioration of non-cardiac surgery patients with ICU referral status who are admitted to the regular ward: a retrospective observational cohort study.

BACKGROUND: Higher-risk surgical patients may not be admitted to the intensive care unit due to stable immediate post-operative status on review. The outcomes of this cohort are not well described. Our aim was to examine the subsequent inpatient course of intensive care unit -referred but not admitted surgical patients. METHODS: All patients aged ≥18 years who were referred but not admitted for post-operative management in a tertiary metropolitan intensive care unit following non-cardiac surgery between 1/7/2017 and 30/6/2018 were eligible for inclusion in this retrospective observational cohort study. Primary outcome was Medical Emergency Team activation. Secondary outcomes included unplanned intensive care unit admission; length of stay; and 30-day mortality. Risk of serious complications and predicted length of stay were calculated using the National Surgical Quality Improvement Program scoring tool. RESULTS: Fifteen of 60 patients (25%) had a MET-call following surgery, eight (13%) patients required unplanned intensive care unit admission, with median (IQR) time to Medical Emergency Team call 9 (6-13) hours. No patients died within 30-days. There was no significant difference between mean National Surgical Quality Improvement Program predicted and actual length of stay; after adjustment, National Surgical Quality Improvement Program predicted risk of serious complications was associated with unplanned intensive care unit admission (OR [95% CI] = 1.08 [1.00-1.16], p = 0.04), although not Medical Emergency Team calls. CONCLUSIONS: Post-operative deterioration occurs frequently, and early, in a cohort of high-risk surgical patients initially assessed as being safe for ward care. Changes to current triage models for post-operative intensive care unit admission may reduce the impact of complications in this high-risk group.

ISARIC-4C Mortality Score overestimates risk of death due to COVID-19 in Australian ICU patients: a validation cohort study.

Objective: To assess the performance of the UK International Severe Acute Respiratory and Emerging Infections Consortium (ISARIC) Coronavirus Clinical Characterisation Consortium (4C) Mortality Score for predicting mortality in Australian patients with coronavirus disease 2019 (COVID-19) requiring intensive care unit (ICU) admission. Design: Multicentre, prospective, observational cohort study. Setting: 78 Australian ICUs participating in the SPRINT-SARI (Short Period Incidence Study of Severe Acute Respiratory Infection) Australia study of COVID-19. Participants: Patients aged 16 years or older admitted to participating Australian ICUs with polymerase chain reaction (PCR)-confirmed COVID-19 between 27 February and 10 October 2020. Main outcome measures: ISARIC-4C Mortality Score, calculated at the time of ICU admission. The primary outcome was observed versus predicted in-hospital mortality (by 4C Mortality and APACHE II). Results: 461 patients admitted to a participating ICU were included. 149 (32%) had complete data to calculate a 4C Mortality Score without imputation. Overall, 61/461 patients (13.2%) died, 16.9% lower than the comparable ISARIC-4C cohort in the United Kingdom. In patients with complete data, the median (interquartile range [IQR]) 4C Mortality Score was 10.0 (IQR, 8.0-13.0) and the observed mortality was 16.1% (24/149) versus 22.9% median predicted risk of death. The 4C Mortality Score discriminatory performance measured by the area under the receiver operating characteristic curve (AUROC) was 0.79 (95% CI, 0.68-0.90), similar to its performance in the original ISARIC-4C UK cohort (0.77) and not superior to APACHE II (AUROC, 0.81; 95% CI, 0.75-0.87). Conclusions: When calculated at the time of ICU admission, the 4C Mortality Score consistently overestimated the risk of death for Australian ICU patients with COVID-19. The 4C Mortality Score may need to be individually recalibrated for use outside the UK and in different hospital settings.

Smoking cessation therapy in Australian and New Zealand intensive care units: a multicentre point prevalence study.

OBJECTIVE: To obtain an accurate estimate of smoking prevalence and smoking cessation support practices, including nicotine replacement therapy (NRT), in Australian and New Zealand intensive care units (ICUs). DESIGN, SETTING AND PARTICIPANTS: Cross-sectional, observational study using data obtained from adult ICUs participating in the Australian and New Zealand Intensive Care Society Clinical Trials Group Point Prevalence Program in 2016. MAIN OUTCOME MEASURES: Prevalence and intensity of current smoking, baseline characteristics of smokers in comparison with non-smokers and frequency of NRT use while admitted to the ICU. RESULTS: Smoking data were present for 551 of 671 adult ICU patients from 47 ICUs on 2 study days in 2016. Of these 551 patients, 112 were current smokers (20.3%; 95% CI, 17.0-23.9%). No significant differences in severity of illness or mortality were observed between smokers and non-smokers. NRT was prescribed to 30/112 smokers (26.8%), and in 28 of those 30 patients (93%) it was administered via nicotine patch alone. Routine prescribing of NRT was practised in 28/47 ICUs (60%), and 24/47 ICUs (51%) had formal protocols or guidelines in place related to supporting smoking cessation. CONCLUSIONS: The prevalence of smoking in Australian and New Zealand ICUs patients is high. Over half of participating ICUs reported the routine prescription of NRT despite uncertainty regarding the practice. Further research evaluating the safety and efficacy of NRT is required.

A "Code ICU" expedited review of critically ill patients is associated with reduced emergency department length of stay and duration of mechanical ventilation.

PURPOSE: To examine the effect of a system of expedited review of critically ill patients in the Emergency Department (ED) on ED length of stay (LOS) and Intensive Care Unit (ICU) outcomes. MATERIALS AND METHODS: Retrospective cohort study at a tertiary hospital comparing two 12-month periods before and after implementation of a 'Code ICU' system of expedited review of critically ill patients in the ED. All adult ED to ICU admissions were included. Separate analyses were performed for patients intubated prior to ICU admission. RESULTS: 622 and 629 patients were included in each time period. During the intervention period more patients had ED LOS<240min in both the total [199 (32.0%) vs. 243 (38.6%), P=0.014; adjusted OR 1.60, 95% CI 1.14-2.25] and intubated cohorts [145 (51.2%) vs. 172 (61.9%), P=0.011; adjusted OR 1.65, 95% CI 1.16-2.36]. 'Code ICU' intubated patients had a shorter duration of mechanical ventilation, ICU LOS and hospital LOS compared to non-'Code ICU' intubated patients. CONCLUSIONS: A system of rapid review of critically ill patients in the ED was associated with reduced ED LOS and improved ICU outcomes.