Thirty years of ANZICS CORE: A clinical quality success story.

In 2023, the Australian and New Zealand Intensive Care Society (ANZICS) Registry run by the Centre for Outcomes and Resources Evaluation (CORE) turns 30 years old. It began with the Adult Patient Database, the Australian and New Zealand Paediatric Intensive Care Registry, and the Critical Care Resources Registry, and it now includes Central Line Associated Bloodstream Infections Registry, the Extra-Corporeal Membrane Oxygenation Database, and the Critical Health Resources Information System. The ANZICS Registry provides comparative case-mix reports, risk-adjusted clinical outcomes, process measures, and quality of care indicators to over 200 intensive care units describing more than 200 000 adult and paediatric admissions annually. The ANZICS CORE outlier management program has been a major contributor to the improved patient outcomes and provided significant cost savings to the healthcare sector. Over 200 peer-reviewed papers have been published using ANZICS Registry data. The ANZICS Registry was a vital source of information during the COVID-19 pandemic. Upcoming developments include reporting of long-term survival and patient-reported outcome and experience measures.

Communication with Families Regarding Organ and Tissue Donation after Death in Intensive Care (COMFORT): a multicentre before-and-after study.

OBJECTIVE: To implement a best-practice intervention offering deceased organ donation, testing whether it increased family consent rates. DESIGN: A multicentre before-and-after study of a prospective cohort compared with pre-intervention controls. SETTING: Nine Australian intensive care units. PARTICIPANTS: Families and health care professionals caring for donor-eligible patients without registered donation preferences or aged ≤ 16 years. INTERVENTION: A multicomponent intervention including offers of deceased organ donation from specially trained designated requesters using a structured conversation separate to end-of-life discussions. MAIN OUTCOME MEASURE: Proportion of families consenting to organ donation. RESULTS: Consent was obtained in 87/164 cases (53%) during the intervention period compared with 14/25 cases (56%) pre-intervention (P = 0.83). The odds ratio (OR) of obtaining consent during the intervention period relative to preintervention was 1.13 (95% CI, 0.48-2.63; P = 0.78). During the intervention period, designated requesters obtained consent in 55/98 cases (56%), compared with 32/66 cases (48%) in which the medical team managing patient care raised donation (P = 0.34). Factors independently associated with increased consent were: family-raised organ donation (OR, 4.34; 95% CI, 1.79-10.52; P = 0.001), presence of an independent designated requester (OR, 3.84; 95% CI, 1.35- 10.98; P = 0.012), and multiple donation conversations per case (OR, 3.35; 95% CI, 1.93-5.81; P < 0.001). Consent decreased when patients were of non-Christian religion (OR, 0.18; 95% CI, 0.04-0.91; P = 0.038) and end-of-life and donation meetings were separate (OR, 0.38; 95% CI, 0.16-0.89; P = 0.026). CONCLUSION: Implementation of a multicomponent intervention did not increase consent rates for organ donation, although some components of the intervention exerted significant effect. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12613000815763. ClinicalTrials.gov: NCT01922310.

Patient groups, clinicians and healthcare professionals agree - all test results need to be seen, understood and followed up.

Background Diagnostic testing provides integral information for the prevention, diagnosis, treatment and management of disease. Inadequate test result reporting and follow-up is a major risk to patient safety. Factors contributing to failure to follow-up test results include unclear delineation of responsibility about who is meant to act on a test result; poor coordination across different levels of care; and the absence of integrated health information systems for the efficient information communication. Methods A 2016 Australian Stakeholder Forum brought together over 30 representatives from 14 different consumer, clinical and management stakeholder organisations to discuss safe and effective test result communication, management and follow-up. Thematic analysis was conducted drawing on multimodal data collected in the form of observational fieldnotes and document artefacts produced by participants. Results The forum identified major challenges which pose immediate risks to patient safety. Participants recommended priorities for addressing issues relating to: (i) the governance of test result management processes; (ii) integration of health care processes through the utilisation of effective digital health solutions; and (iii) involving patients as key partners in the decision-making and care process. Conclusions Stakeholder groups diverged slightly in their priorities. Consumers highlighted the lack of patient involvement in the test result management process but were less concerned about standardisation of reports and critical result thresholds than pathologists. The forum foregrounded the need for a systems approach, capable of identifying and addressing interconnections and multiple factors that contribute to poor test result follow-up, with a strong emphasis on enhancing the contribution of patients.

Delivering safe and effective test-result communication, management and follow-up: a mixed-methods study protocol.

INTRODUCTION: The failure to follow-up pathology and medical imaging test results poses patient-safety risks which threaten the effectiveness, quality and safety of patient care. The objective of this project is to: (1) improve the effectiveness and safety of test-result management through the establishment of clear governance processes of communication, responsibility and accountability; (2) harness health information technology (IT) to inform and monitor test-result management; (3) enhance the contribution of consumers to the establishment of safe and effective test-result management systems. METHODS AND ANALYSIS: This convergent mixed-methods project triangulates three multistage studies at seven adult hospitals and one paediatric hospital in Australia.Study 1 adopts qualitative research approaches including semistructured interviews, focus groups and ethnographic observations to gain a better understanding of test-result communication and management practices in hospitals, and to identify patient-safety risks which require quality-improvement interventions.Study 2 analyses linked sets of routinely collected healthcare data to examine critical test-result thresholds and test-result notification processes. A controlled before-and-after study across three emergency departments will measure the impact of interventions (including the use of IT) developed to improve the safety and quality of test-result communication and management processes.Study 3 adopts a consumer-driven approach, including semistructured interviews, and the convening of consumer-reference groups and community forums. The qualitative data will identify mechanisms to enhance the role of consumers in test-management governance processes, and inform the direction of the research and the interpretation of findings. ETHICS AND DISSEMINATION: Ethical approval has been granted by the South Eastern Sydney Local Health District Human Research Ethics Committee and Macquarie University. Findings will be disseminated in academic, industry and consumer journals, newsletters and conferences.

Technology meets tradition: The perceived impact of the introduction of information and communication technology on ward rounds in the intensive care unit.

BACKGROUND: Public policy in many health systems is currently dominated by the quest to find ways to 'do more with less'-to achieve better outcomes at a reduced cost. The success or failure of initiatives in support of this quest are often understood in terms of an adversarial dynamic or struggle between the professional logics of medicine and of management. Here, we use the case of the introduction of information and communication technology (ICT) to a well-established ritual of medical autonomy (the medical ward round) to articulate a more nuanced explanation of how and why new ways of working with technology are accepted and adopted (or not). METHODS: The study was conducted across four intensive care units (ICUs) in major teaching hospitals in Sydney, Australia. Using interviews, we examined 48 doctors' perceptions of the impact of ICT on ward round practice. We applied the concept of institutional logics to frame our analysis. Interview transcripts were analysed using a hybrid of deductive and inductive thematic analysis. RESULTS: The doctors displayed a complex engagement with the technology that belies simplistic characterisations of medical rejection of managerial encroachment. In fact, they selectively welcomed into the ward round aspects of the technology which reinforced the doctor's place in the healthcare hierarchy and which augmented their role as scientists. At the same time, they guarded against allowing managerial logic embedded in ICT to de-emphasise their embodied subjectivity in relation to the patient as a person rather than as a collection of parameters. CONCLUSION: ICT can force the disruption of some aspects of existing routines, even where these are long-established rituals. Resistance arose when the new technology did not fit with the 'logic of care'. Incorporation of the logic of care into the design and customisation of clinical information systems is a challenge and potentially counterproductive, because it could attempt to apply a technological fix to what is essentially a social problem. However, there are significant opportunities to ensure that new technologies do not obstruct doctors' roles as carers nor disrupt the embodied relationship they need to have with patients.

COMmunication with Families regarding ORgan and Tissue donation after death in intensive care (COMFORT): protocol for an intervention study.

BACKGROUND: Discussing deceased organ donation can be difficult not only for families but for health professionals who initiate and manage the conversations. It is well recognised that the methods of communication and communication skills of health professionals are key influences on decisions made by families regarding organ donation. METHODS: This multicentre study is being performed in nine intensive care units with follow-up conducted by the Organ and Tissue Donation Service in New South Wales (NSW) Australia. The control condition is pre-intervention usual practice for at least six months before each site implements the intervention. The COMFORT intervention consists of six elements: family conversations regarding offers for organ donation to be led by a "designated requester"; family offers for donation are deferred to the designated requester; the offer of donation is separated from the end-of-life discussion that death is inevitable; it takes place within a structured family donation conversation using a "balanced" approach. Designated requesters may be intensivists, critical care nurses or social workers prepared by attending the three-day national "Family Donation Conversation" workshops, and the half-day NSW Simulation Program. The design is pre-post intervention to compare rates of family consent for organ donation six months before and under the intervention. Each ICU crosses from using the control to intervention condition after the site initiation visit. The primary endpoint is the consent rate for deceased organ donation calculated from 140 eligible next of kin families. Secondary endpoints are health professionals' adherence rates to core elements of the intervention; identification of predictors of family donation decision; and the proportion of families who regret their final donation decision at 90 days. DISCUSSION: The pragmatic design of this study may identify 'what works' in usual clinical settings when requesting organ donation in critical care areas, both in terms of changes in practice healthcare professionals are willing and able to adopt, and the effect this may have on desired outcomes. The findings of this study will be indicative of the potential benefits of the intervention and be relevant and transferrable to clinical settings in other states and countries. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613000815763 (24 July 2013). ClinicalTrials.gov: NCT01922310 (14 August 2013) (retrospectively registered).

Clinical care standards: appropriate care everywhere - acute coronary syndromes as an example.

Audit data show that despite clinical practice guidelines, some patients miss out on evidence-based care, which is not explained by individual needs or preferences. Clinical care standards are small sets of concise recommendations that focus on known gaps in evidence-based care for a particular clinical condition. They aim to ensure that all patients with the same clinical condition are offered appropriate care, regardless of their location. Clinical care standards are nationally agreed standards and are developed to maximise engagement of consumers, clinicians, health services, and state and territory health departments and agencies. They complement clinical practice guidelines and other initiatives for improving quality of health care. As an example, the Acute Coronary Syndromes (ACS) Clinical Care Standard is a significant step forward in supporting clinicians and health services to realise all of the gains promised by the ACS evidence base. The ACS Clinical Care Standard focuses on the areas of care that are known to be most associated with variation in outcome. It supports patient involvement in critical decisions that affect their care, refocuses clinicians on the priority areas of ensuring appropriate ACS care, and informs health services about the systems required to deliver evidence-based care.

Traditional landmark versus ultrasound guided tracheal puncture during percutaneous dilatational tracheostomy in adult intensive care patients: a randomised controlled trial.

INTRODUCTION: Long-term ventilated intensive care patients frequently require tracheostomy. Although overall risks are low, serious immediate and late complications still arise. Real-time ultrasound guidance has been proposed to decrease complications and improve the accuracy of the tracheal puncture. We aimed to compare the procedural safety and efficacy of real-time ultrasound guidance with the traditional landmark approach during percutaneous dilatational tracheostomy (PDT). METHODS: A total of 50 patients undergoing PDT for clinical indications were randomly assigned, after obtaining informed consent, to have the tracheal puncture procedure carried out using either traditional anatomical landmarks or real-time ultrasound guidance. Puncture position was recorded via bronchoscopy. Blinded assessors determined in a standardised fashion the deviation of the puncture off midline and whether appropriate longitudinal position between the first and fourth tracheal rings was achieved. Procedural safety and efficacy data, including complications and number of puncture attempts required, were collected. RESULTS: In total, 47 data sets were evaluable. Real-time ultrasound guidance resulted in significantly more accurate tracheal puncture. Mean deviation from midline was 15 ± 3° versus 35 ± 5° (P = 0.001). The proportion of appropriate punctures, defined a priori as 0 ± 30° from midline, was significantly higher: 20 (87%) of 23 versus 12 (50%) of 24 (RR = 1.74; 95% CI = 1.13 to 2.67; P = 0.006). First-pass success rate was 20 (87%) of 23 in the ultrasound group and 14 (58%) of 24 in the landmark group (RR = 1.49; 95% CI = 1.03 to 2.17; P = 0.028). The observed decrease in procedural complications was not statistically significant: 5 (22%) of 23 in the ultrasound group versus 9 (37%) of 24 in the landmark group (RR = 0.58; 95% CI = 0.23 to 1.47; P = 0.24). CONCLUSIONS: Ultrasound guidance significantly improved the rate of first-pass puncture and puncture accuracy. Fewer procedural complications were observed; however, this did not reach statistical significance. These results support wider general use of real-time ultrasound guidance as an additional tool to improve PDT. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ID: ACTRN12611000237987 (registered 4 March 2011).

Nutrition support during extracorporeal membrane oxygenation (ECMO) in adults: a retrospective audit of 86 patients.

PURPOSE: Extracorporeal membrane oxygenation (ECMO) is increasingly being used to support critically ill patients with severe cardiac and/or respiratory failure. It has been claimed that the resulting haemodynamic alterations, particularly in venoarterial ECMO, mean that enteral feeding is unsafe and/or poorly tolerated. This study aims to investigate this question and to identify any barriers to optimal nutrition. METHODS: Data were retrospectively collected for 86 patients who received ECMO between January 2007 and July 2012 in a tertiary critical care unit/ECMO referral centre. All were fed using existing protocols that emphasise early enteral feeding in preference over parenteral or delayed enteral nutrition. RESULTS: Thirty-one patients required ECMO for cardiac failure, and all of these received venoarterial ECMO; the remainder received venovenous ECMO. Enteral feeds started for all patients at average 13.1 h [standard deviation (SD) 16.7 h] after ICU admission, reaching goal rate on day 2.6 (SD 1.4). Thirty-three patients experienced significant feeding intolerance during the first 5 days, but of these 20 were managed effectively with prokinetic medications; 18 required parenteral nutrition to supplement inadequately tolerated tube feeds. Intolerance did not differ between ECMO modes. Overall patients tolerated 79.7% of goal nutrition each day in the first 2 weeks. CONCLUSIONS: Enteral feeding can be well tolerated by patients who are receiving ECMO, whether in venovenous or venoarterial mode. ECMO should not exclude patients from receiving the well-documented benefits of early enteral feeding in critical illness.

Aseptic insertion of central venous lines to reduce bacteraemia.

OBJECTIVE: To reduce the rate of central line-associated bacteraemia (CLAB). DESIGN: A collaborative quality improvement project in intensive care units (ICUs) to promote aseptic insertion of central venous lines (CVLs). A checklist was used to record compliance with all aspects of aseptic CVL insertion, with maximal sterile barrier precautions for clinicians ("clinician bundle") and patients ("patient bundle"). CLAB was identified and reported using a standard surveillance definition. PARTICIPANTS AND SETTING: Patients and clinicians in 37 ICUs in New South Wales, July 2007-December 2008. MAIN OUTCOME MEASURES: Compliance with aseptic CVL insertion; rates of CLAB. RESULTS: 10 890 CVL checklists were reviewed for compliance with the clinician and patient bundles: compliance with aseptic CVL insertion improved significantly (P < 0.001). The CLAB rate dropped from 3.0 to 1.2 per 1000 line-days (P < 0.001). Regardless of CVL type, the relative risk (RR) of CLAB in patients with CVLs inserted by clinicians not compliant with the clinician bundle was 1.62 times greater (95% CI, 1.1-2.4; P = 0.018) than the RR with CVLs inserted by clinicians compliant with both bundles. Compliance with both the bundles was associated with a 50% reduction in risk of CLAB (RR, 0.5; 95% CI, 0.4-0.8; P = 0.004). CONCLUSIONS: Compliance with all aspects of aseptic CVL insertion significantly reduces the risk of CLAB. A difficulty we experienced was that most ICUs lacked the organisation and staff to support quality improvement and audit.

Introduction of a new observation chart and education programme is associated with higher rates of vital-sign ascertainment in hospital wards.

INTRODUCTION Local and national awareness of the need to improve the recognition and response to the clinical deterioration of hospital inpatients is high. The authors designed and implemented a programme to improve recognition of deteriorating patients in their hospital; a new observation chart for vital signs was one of the major elements. The aim of the study is to evaluate the impact of the new chart and associated education programme on the completeness of vital-sign recording in ward areas. METHODS The setting is a university-affiliated teaching hospital in Sydney, Australia. Three study periods, each lasting 14 days (preintervention, 2 weeks postintervention, 3 months postintervention), were carried out in three wards. The new observation chart was supported by an education programme. The primary outcome measures were the ascertainment rates of individual vital signs as a proportion of total observation sets. RESULTS Documentation of respiratory rate increased from 47.8% to 97.8% (p<0.001) and was sustained at 3 months postintervention (98.5%). Collection of a full set of vital signs also improved by a similar magnitude. Basic neurological observation for all patients was introduced in the new chart; the uptake of this was very good (93.1%). Ascertainment rates of blood pressure and oxygen saturation also increased by small but significant amounts from good baseline rates of 97% or higher. CONCLUSION The introduction of a new observation chart, and education regarding its use and importance, was associated with a major improvement in the recording of respiratory rate and other vital signs.

Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome.

CONTEXT: The novel influenza A(H1N1) pandemic affected Australia and New Zealand during the 2009 southern hemisphere winter. It caused an epidemic of critical illness and some patients developed severe acute respiratory distress syndrome (ARDS) and were treated with extracorporeal membrane oxygenation (ECMO). OBJECTIVES: To describe the characteristics of all patients with 2009 influenza A(H1N1)-associated ARDS treated with ECMO and to report incidence, resource utilization, and patient outcomes. DESIGN, SETTING, AND PATIENTS: An observational study of all patients (n = 68) with 2009 influenza A(H1N1)-associated ARDS treated with ECMO in 15 intensive care units (ICUs) in Australia and New Zealand between June 1 and August 31, 2009. MAIN OUTCOME MEASURES: Incidence, clinical features, degree of pulmonary dysfunction, technical characteristics, duration of ECMO, complications, and survival. RESULTS: Sixty-eight patients with severe influenza-associated ARDS were treated with ECMO, of whom 61 had either confirmed 2009 influenza A(H1N1) (n = 53) or influenza A not subtyped (n = 8), representing an incidence rate of 2.6 ECMO cases per million population. An additional 133 patients with influenza A received mechanical ventilation but no ECMO in the same ICUs. The 68 patients who received ECMO had a median (interquartile range [IQR]) age of 34.4 (26.6-43.1) years and 34 patients (50%) were men. Before ECMO, patients had severe respiratory failure despite advanced mechanical ventilatory support with a median (IQR) Pao(2)/fraction of inspired oxygen (Fio(2)) ratio of 56 (48-63), positive end-expiratory pressure of 18 (15-20) cm H(2)O, and an acute lung injury score of 3.8 (3.5-4.0). The median (IQR) duration of ECMO support was 10 (7-15) days. At the time of reporting, 48 of the 68 patients (71%; 95% confidence interval [CI], 60%-82%) had survived to ICU discharge, of whom 32 had survived to hospital discharge and 16 remained as hospital inpatients. Fourteen patients (21%; 95% CI, 11%-30%) had died and 6 remained in the ICU, 2 of whom were still receiving ECMO. CONCLUSIONS: During June to August 2009 in Australia and New Zealand, the ICUs at regional referral centers provided mechanical ventilation for many patients with 2009 influenza A(H1N1)-associated respiratory failure, one-third of whom received ECMO. These ECMO-treated patients were often young adults with severe hypoxemia and had a 21% mortality rate at the end of the study period.

Handover--Enabling Learning in Communication for Safety (HELiCS): a report on achievements at two hospital sites.

Clinical handover is an area of critical concern, because deficiencies in handover pose a patient safety risk. Redesign of handover must allow for input from frontline staff to ensure that designs fit into existing practices and settings. The HELiCS (Handover--Enabling Learning in Communication for Safety) tool uses a "video-reflexive" technique: handover encounters are videotaped and played back to the practitioners involved for analysis and discussion. Using the video-reflexive process, staff of an emergency department and an intensive care unit at two different tertiary hospitals redesigned their handover processes. The HELiCS study gave staff greater insight into previously unrecognised clinical and operational problems, enhanced coordination and efficiency of care, and strengthened junior-senior communication and teaching. Our study showed that reflexive and "bottom-up" handover redesign can produce outcomes that harbour local fit, practitioner ownership and (to date) sustainability.

Introduction of enhancement technologies into the intensive care service, Royal Prince Alfred Hospital, Sydney.

In order to achieve the full potential of information technology in healthcare, information systems must have the ability to share and exchange data, which requires the support of standardised medical terminology, such as Systematised Nomenclature of Medicine--Clinical Terms (SNOMED-CT). The Royal Prince Alfred Intensive Care Service and the School of Information Technologies, University of Sydney have been collaborating for over two years, developing pioneering software initiatives for clinical information systems (CIS). More recently, the collaboration resulted in the development of two prototype systems. The Ward Round Information System (WRIS) has been designed to convert clinicians' clinical notes into the formal medical encoding ontology SNOMED-CT, thus enabling more consistent descriptions of patient conditions and allowing large-scale retrieval and analysis from the narrative part of the patient record. In addition, a Clinical Data Analytics Language (CDAL) system has also been developed and is designed to answer questions of the data stored in the CIS. It will assist clinicians in the management of vast amounts of complex information generated during an ICU admission and ultimately improve the quality and efficiency of care. CDAL provides clinicians with the ability to frame any question about their data in their database and get the answer almost immediately. Both systems went live in October 2007, and this report summarises the background, purpose, and progress thus far.

Development and implementation of a high-quality clinical database: the Australian and New Zealand Intensive Care Society Adult Patient Database.

OBJECTIVE: To describe the development of a binational intensive care database. SETTING: One hundred thirty-eight intensive care units (ICUs) in Australia and New Zealand. METHODS: A structure was developed to enable ICUs to submit data for central and local analysis. Reports were developed to allow comparison with similar ICU types and against published mortality prediction models. The database was evaluated according to (a) the criteria of the Directory of Clinical Databases (DoCDat) and (b) a proposed framework for data quality assurance in medical registries. RESULTS: Between January 1987 and December 2003, 444,147 data sets were collected from 121 (72.5%) of 167 Australian and 10 (37.0%) of 27 New Zealand ICUs. Data sets from more than 60000 ICU admissions were submitted in 2003. Overall hospital mortality was 14.5%. The mean quality level achieved according to DoCDat criteria was high as was performance against a proposed framework for data quality. The provision of no-cost software has been vitally important to the success of the database. CONCLUSION: A high-quality ICU database has successfully been implemented in Australia and New Zealand and is now used as a routine quality assurance and peer review tool. Similar developments may be both possible and desirable in other countries.