Extracorporeal Carbon Dioxide Removal With the Hemolung in Patients With Acute Respiratory Failure: A Multicenter Retrospective Cohort Study.

OBJECTIVES: Extracorporeal carbon dioxide removal (ECCO 2 R) devices are effective in reducing hypercapnia and mechanical ventilation support but have not been shown to reduce mortality. This may be due to case selection, device performance, familiarity, or the management. The objective of this study is to investigate the effectiveness and safety of a single ECCO 2 R device (Hemolung) in patients with acute respiratory failure and identify variables associated with survival that could help case selection in clinical practice as well as future research. DESIGN: Multicenter, multinational, retrospective review. SETTING: Data from the Hemolung Registry between April 2013 and June 2021, where 57 ICUs contributed deidentified data. PATIENTS: Patients with acute respiratory failure treated with the Hemolung. The characteristics of patients who survived to ICU discharge were compared with those who died. Multivariable logistical regression analysis was used to identify variables associated with ICU survival. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 159 patients included, 65 (41%) survived to ICU discharge. The survival was highest in status asthmaticus (86%), followed by acute respiratory distress syndrome (ARDS) (52%) and COVID-19 ARDS (31%). All patients had a significant reduction in Pa co2 and improvement in pH with reduction in mechanical ventilation support. Patients who died were older, had a lower Pa o2 :F io2 (P/F) and higher use of adjunctive therapies. There was no difference in the complications between patients who survived to those who died. Multivariable regression analysis showed non-COVID-19 ARDS, age less than 65 years, and P/F at initiation of ECCO 2 R to be independently associated with survival to ICU discharge (P/F 100-200 vs <100: odds ratio, 6.57; 95% CI, 2.03-21.33). CONCLUSIONS: Significant improvement in hypercapnic acidosis along with reduction in ventilation supports was noted within 4 hours of initiating ECCO 2 R. Non-COVID-19 ARDS, age, and P/F at commencement of ECCO 2 R were independently associated with survival.

Activin A level is associated with physical function in critically ill patients.

BACKGROUND: Activin A is a potent negative regulator of muscle mass elevated in critical illness. It is unclear whether muscle strength and physical function in critically ill humans are associated with elevated activin A levels. OBJECTIVES: The objective of this study was to investigate the relationship between serum activin A levels, muscle strength, and physical function at discharge from the intensive care unit (ICU) and hospital. METHODS: Thirty-six participants were recruited from two tertiary ICUs in Melbourne, Australia. Participants were included if they were mechanically ventilated for >48 h and expected to have a total ICU stay of >5 days. The primary outcome measure was the Six-Minute Walk Test distance at hospital discharge. Secondary outcome measures included handgrip strength, Medical Research Council Sum Score, Physical Function ICU Test Scored, Six-Minute Walk Test, and Timed Up and Go Test assessed throughout the hospital admission. Total serum activin A levels were measured daily in the ICU. RESULTS: High peak activin A was associated with worse Six-Minute Walk Test distance at hospital discharge (linear regression coefficient, 95% confidence interval, p-value: -91.3, -154.2 to -28.4, p = 0.007, respectively). Peak activin A concentration was not associated with the secondary outcome measures. CONCLUSIONS: Higher peak activin A may be associated with the functional decline of critically ill patients. Further research is indicated to examine its potential as a therapeutic target and a prospective predictor for muscle wasting in critical illness. STUDY REGISTRATION: ACTRN12615000047594.

Management of Clostridioides difficile infection in adults and challenges in clinical practice: review and comparison of current IDSA/SHEA, ESCMID and ASID guidelines.

Clostridioides difficile infection (CDI) remains a significant clinical challenge both in the management of severe and severe-complicated disease and the prevention of recurrence. Guidelines released by the Infectious Diseases Society of America and Society for Healthcare Epidemiology of America (IDSA/SHEA) and ESCMID had some consensus as well as some discrepancies in disease severity classification and treatment recommendations. We review and compare the key clinical strategies from updated IDSA/SHEA, ESCMID and current Australasian guidelines for CDI management in adults and discuss relevant issues for clinicians, particularly in the management of severe-complicated infection. Updated IDSA/SHEA and ESCMID guidelines now reflect the increased efficacy of fidaxomicin in preventing recurrence and have both promoted fidaxomicin to first-line therapy with an initial CDI episode in both non-severe and severe disease and endorsed the role of bezlotoxumab in the prevention of recurrent infection. Vancomycin remains acceptable therapy and metronidazole is not preferred. For severe-complicated infection the IDSA/SHEA recommends high-dose oral ±â€Šrectal vancomycin and IV metronidazole, whilst in an important development, ESCMID has endorsed fidaxomicin and tigecycline as part of combination anti-CDI therapy, for the first time. The role of faecal microbiota transplantation (FMT) in second CDI recurrence is now clearer, but timing and mode of FMT in severe-complicated refractory disease still requires further study.

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.

BACKGROUND: The 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. METHODS: In 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). RESULTS: 7001 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). CONCLUSION: Both 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 frailty on clinical outcomes in patients with and without COVID-19 pneumonitis admitted to intensive care units in Australia and New Zealand: a retrospective registry data analysis.

BACKGROUND: It is unclear if the impact of frailty on mortality differs between patients with viral pneumonitis due to COVID-19 or other causes. We aimed to determine if a difference exists between patients with and without COVID-19 pneumonitis. METHODS: This multicentre, retrospective, cohort study using the Australian and New Zealand Intensive Care Society Adult Patient Database included patients aged ≥ 16 years admitted to 153 ICUs between 01/012020 and 12/31/2021 with admission diagnostic codes for viral pneumonia or acute respiratory distress syndrome, and Clinical Frailty Scale (CFS). The primary outcome was hospital mortality. RESULTS: A total of 4620 patients were studied, and 3077 (66.6%) had COVID-19. The patients with COVID-19 were younger (median [IQR] 57.0 [44.7-68.3] vs. 66.1 [52.0-76.2]; p < 0.001) and less frail (median [IQR] CFS 3 [2-4] vs. 4 [3-5]; p < 0.001) than non-COVID-19 patients. The overall hospital mortality was similar between the patients with and without COVID-19 (14.7% vs. 14.9%; p = 0.82). Frailty alone as a predictor of mortality showed only moderate discrimination in differentiating survivors from those who died but was similar between patients with and without COVID-19 (AUROC 0.68 vs. 0.66; p = 0.42). Increasing frailty scores were associated with hospital mortality, after adjusting for Australian and New Zealand Risk of Death score and sex. However, the effect of frailty was similar in patients with and without COVID-19 (OR = 1.29; 95% CI: 1.19-1.41 vs. OR = 1.24; 95% CI: 1.11-1.37). CONCLUSION: The presence of frailty was an independent risk factor for mortality. However, the impact of frailty on outcomes was similar in COVID-19 patients compared to other causes of viral pneumonitis.

Association between frailty and clinical outcomes in surgical patients admitted to intensive care units: a systematic review and meta-analysis.

BACKGROUND: Preoperative frailty may be a strong predictor of adverse postoperative outcomes. We investigated the association between frailty and clinical outcomes in surgical patients admitted to the ICU. METHODS: PubMed, Embase, and Ovid MEDLINE were searched for relevant articles. We included full-text original English articles that used any frailty measure, reporting results of surgical adult patients (≥18 yr old) admitted to ICUs with mortality as the main outcome. Data on mortality, duration of mechanical ventilation, ICU and hospital length of stay, and discharge destination were extracted. The quality of included studies and risk of bias were assessed using the Newcastle Ottawa Scale. Data were synthesised according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. RESULTS: Thirteen observational studies met inclusion criteria. In total, 58 757 patients were included; 22 793 (39.4%) were frail. Frailty was associated with an increased risk of short-term (risk ratio [RR]=2.66; 95% confidence interval [CI]: 1.99-3.56) and long-term mortality (RR=2.66; 95% CI: 1.32-5.37). Frail patients had longer ICU length of stay (mean difference [MD]=1.5 days; 95% CI: 0.8-2.2) and hospital length of stay (MD=3.9 days; 95% CI: 1.4-6.5). Duration of mechanical ventilation was longer in frail patients (MD=22 h; 95% CI: 1.7-42.3) and they were more likely to be discharged to a healthcare facility (RR=2.34; 95% CI: 1.36-4.01). CONCLUSION: Patients with frailty requiring postoperative ICU admission for elective and non-elective surgeries had increased risk of mortality, lengthier admissions, and increased likelihood of non-home discharge. Preoperative frailty assessments and risk stratification are essential in patient and clinician planning, and critical care resource utilisation. CLINICAL TRIAL REGISTRATION: PROSPERO CRD42020210121.

Association between frailty and clinical outcomes in hospitalised patients requiring Code Blue activation.

BACKGROUND: Code Blues allow a rapid, hospital wide response to acutely deteriorating patients. The concept of frailty is being increasingly recognised as an important element in determining outcomes of critically ill patients. We hypothesised that increasing frailty would be associated with worse outcomes following a Code Blue. AIMS: To investigate the association between increasing frailty and outcomes of Code Blues. METHODS: Single-centre retrospective design of patients admitted to Frankston Hospital in Australia between 1 January 2013 and 31 December 2017 who triggered a Code Blue. Frailty evaluation was made based on electronic medical records as were the details and the outcomes of the Code Blue. The primary outcome measure was a composite of hospital mortality or Cerebral Performance Categories scale ≥3. Secondary outcomes included the immediate outcome of the Code Blue and hospital mortality. RESULTS: One hundred and forty-eight of 911 screened patients were included in the final analysis. Seventy-three were deemed 'frail' and the remainder deemed 'fit'. Seventy-eight percent of frail patients reached the primary outcome, compared with 41% of fit patients (P < 0.001). Multivariable analysis demonstrated frailty to be associated with primary outcome (odds ratio = 2.87; 95% confidence interval (CI) 1.28-6.44; P = 0.01). A cardiac aetiology for the Code Blue was also associated with an increased odds of primary outcome (OR = 3.52; 95% CI 1.51-8.05; P = 0.004). CONCLUSIONS: Frailty is independently associated with the composite outcome of hospital mortality or severe disability following a Code Blue. Frailty is an important tool in prognostication for these patients and might aid in discussions regarding treatment limitations.

Timely goals of care documentation in patients with frailty in the COVID-19 era: a retrospective multi-site study.

BACKGROUND: Older frail patients are more likely to have timely goals of care (GOC) documentation than non-frail patients. AIMS: To investigate whether timely documentation of GOC within 72 h differed in the context of the COVID-19 pandemic (2020), compared with the pre-COVID-19 era (2019) for older frail patients. METHODS: Multi-site retrospective cohort study was conducted in two public hospitals where all consecutive frail adult patients aged ≥65 years were admitted under medical units for at least 24 h between 1 March 31 and October in 2019 and between 1 March and 31 October 2020 were included. The GOC was derived from electronic records. Frailty status was derived from hospital coding data using hospital frailty risk score (frail ≥5). The primary outcome was the documentation of GOC within 72 h of hospital admission. Secondary outcomes included hospital mortality, rapid response call, intensive care unit admission, prolonged hospital length of stay (≥10 days) and time to the documentation of GOC. RESULTS: The study population comprised 2021 frail patients admitted in 2019 and 1849 admitted in 2020, aged 81.2 and 90.9 years respectively. The proportion of patients with timely GOC was lower in 2020, than 2019 (48.3% (893/1849) vs 54.9% (1109/2021); P = 0.021). After adjusting for confounding factors, patients in 2020 were less likely to receive timely GOC (odds ratio = 0.77; 95% confidence interval (CI) 0.68-0.88). Overall time to GOC documentation was longer in 2020 (hazard ratio = 0.86; 95% CI 0.80-0.93). CONCLUSION: Timely GOC documentation occurred less frequently in frail patients during the COVID-19 pandemic than in the pre-COVID-19 era.

Defining ICD-10 surrogate variables to estimate the modified frailty index: a Delphi-based approach.

BACKGROUND: There are currently no validated globally and freely available tools to estimate the modified frailty index (mFI). The widely available and non-proprietary International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) coding could be used as a surrogate for the mFI. We aimed to establish an appropriate set of the ICD-10 codes for comorbidities to be used to estimate the eleven-variable mFI. METHODS: A three-stage, web-based, Delphi consensus-building process among a panel of intensivists and geriatricians using iterative rounds of an online survey, was conducted between March and July 2021. The consensus was set a priori at 75% overall agreement. Additionally, we assessed if survey responses differed between intensivists and geriatricians. Finally, we ascertained the level of agreement. RESULTS: A total of 21 clinicians participated in all 3 Delphi surveys. Most (86%, 18/21) had more than 5-years' experience as specialists. The agreement proportionately increased with every Delphi survey. After the third survey, the panel had reached 75% consensus in 87.5% (112/128) of ICD-10 codes. The initially included 128 ICD-10 variables were narrowed down to 54 at the end of the 3 surveys. The inter-rater agreements between intensivists and geriatricians were moderate for surveys 1 and 3 (κ = 0.728, κ = 0.780) respectively, and strong for survey 2 (κ = 0.811). CONCLUSIONS: This quantitative Delphi survey of a panel of experienced intensivists and geriatricians achieved consensus for appropriate ICD-10 codes to estimate the mFI. Future studies should focus on validating the mFI estimated from these ICD-10 codes. TRIAL REGISTRATION: Not applicable.

Risk perception and emotional wellbeing in healthcare workers involved in rapid response calls during the COVID-19 pandemic: A substudy of a cross-sectional survey.

BACKGROUND: Coronavirus disease-2019 (COVID-19) has effected major changes to healthcare delivery within acute care settings. Rapid response calls (RRCs) in healthcare organisations have been effective at identifying and urgently managing acute clinical deterioration. Code-95 RRC were introduced to prewarn healthcare workers (HCWs) attending to patients suspected or confirmed with COVID-19 infection. AIMS: The primary aim of the study was to identify the personal impact of the COVID-19 pandemic on HCWs involved in attending Code-95 RRC. We sought to evaluate their perception of risks and effects on wellbeing and identify potential opportunities for improvement at organisational levels. METHODS: We undertook a detailed survey on HCWs attending Code-95 RRCs, including questions that sought to understand the impact of the pandemic as well as their perception of infection risk and emotional wellbeing. This was a substudy of the prospective cross-sectional single-centre survey of HCWs that was conducted over a 3-week period at Frankston Hospital, Victoria, Australia. We adopted a quantitative content analysis approach for free-text responses in this secondary analysis. RESULTS: Four hundred two free-text comments were received from 297 respondents and were analysed. More than two-thirds (68%, 223/297) were female. Of all comments, 39% (155/402) were related to organisational issues including communication, confusion due to constantly changing infection control policies, and insufficient training. Thirty-three percent of comments (133/402) raised issues regarding the adequacy of personal protective equipment. Anxiety was reported in 25% of comments (101/402) with concerns predominantly relating to emotional stress and fatigue, risks of virus exposure and transmitting the infection to others, and COVID-19 precautions impairing care delivery. CONCLUSION(S): Our study raises important issues that have relevance for all healthcare organisations in the management of patients with COVID-19. These include the importance of improving communication, especially when infection control policies are revised, optimising training, maintaining adequate personal protective equipment, and HCW support. Early recognition and management of these issues are crucial to maintain optimal healthcare delivery.

Prone Positioning of Nonintubated Patients With Coronavirus Disease 2019-A Systematic Review and Meta-Analysis.

OBJECTIVES: Several studies have reported prone positioning of nonintubated patients with coronavirus diseases 2019-related hypoxemic respiratory failure. This systematic review and meta-analysis evaluated the impact of prone positioning on oxygenation and clinical outcomes. DESIGN AND SETTING: We searched PubMed, Embase, and the coronavirus diseases 2019 living systematic review from December 1, 2019, to November 9, 2020. SUBJECTS AND INTERVENTION: Studies reporting prone positioning in hypoxemic, nonintubated adult patients with coronavirus diseases 2019 were included. MEASUREMENTS AND MAIN RESULTS: Data on prone positioning location (ICU vs non-ICU), prone positioning dose (total minutes/d), frequency (sessions/d), respiratory supports during prone positioning, relative changes in oxygenation variables (peripheral oxygen saturation, Pao2, and ratio of Pao2 to the Fio2), respiratory rate pre and post prone positioning, intubation rate, and mortality were extracted. Twenty-five observational studies reporting prone positioning in 758 patients were included. There was substantial heterogeneity in prone positioning location, dose and frequency, and respiratory supports provided. Significant improvements were seen in ratio of Pao2 to the Fio2 (mean difference, 39; 95% CI, 25-54), Pao2 (mean difference, 20 mm Hg; 95% CI, 14-25), and peripheral oxygen saturation (mean difference, 4.74%; 95% CI, 3-6%). Respiratory rate decreased post prone positioning (mean difference, -3.2 breaths/min; 95% CI, -4.6 to -1.9). Intubation and mortality rates were 24% (95% CI, 17-32%) and 13% (95% CI, 6-19%), respectively. There was no difference in intubation rate in those receiving prone positioning within and outside ICU (32% [69/214] vs 33% [107/320]; p = 0.84). No major adverse events were recorded in small subset of studies that reported them. CONCLUSIONS: Despite the significant variability in frequency and duration of prone positioning and respiratory supports applied, prone positioning was associated with improvement in oxygenation variables without any reported serious adverse events. The results are limited by a lack of controls and adjustments for confounders. Whether this improvement in oxygenation results in meaningful patient-centered outcomes such as reduced intubation or mortality rates requires testing in well-designed randomized clinical trials.

Comparison of clinical outcomes between nurse practitioner and registrar-led medical emergency teams: a propensity-matched analysis.

OBJECTIVE: Medical emergency teams (MET) are mostly led by physicians. Some hospitals are currently using nurse practitioners (NP) to lead MET calls. These are no studies comparing clinical outcomes between these two care models. To determine whether NP-led MET calls are associated with lower risk of acute patient deterioration, when compared to intensive care (ICU) registrar (ICUR)-led MET calls. METHODS: The composite primary outcome included recurrence of MET call, occurrence of code blue or ICU admission within 24 h. Secondary outcomes were mortality within 24 h of MET call, length of hospital stay, hospital mortality and proportion of patients discharged home. Propensity score matching was used to reduce selection bias from confounding factors between the ICUR and NP group. RESULTS: A total of 1343 MET calls were included (1070 NP, 273 ICUR led). On Univariable analysis, the incidence of the primary outcome was higher in ICUR-led MET calls (26.7% vs. 20.6%, p = 0.03). Of the secondary outcome measures, mortality within 24 h (3.4% vs. 7.7%, p = 0.002) and hospital mortality (12.7% vs. 20.5%, p = 0.001) were higher in ICUR-led MET calls. Propensity score-matched analysis of 263 pairs revealed the composite primary outcome was comparable between both groups, but NP-led group was associated with reduced risk of hospital mortality (OR 0.57, 95% CI 0.35-0.91, p = 0.02) and higher likelihood of discharge home (OR 1.55, 95% CI 1.09-2.2, p = 0.015). CONCLUSION: Acute patient deterioration was comparable between ICUR- and NP-led MET calls. NP-led MET calls were associated with lower hospital mortality and higher likelihood of discharge home.

Incidence and management of metabolic acidosis with sodium bicarbonate in the ICU: An international observational study.

BACKGROUND: Metabolic acidosis is a major complication of critical illness. However, its current epidemiology and its treatment with sodium bicarbonate given to correct metabolic acidosis in the ICU are poorly understood. METHOD: This was an international retrospective observational study in 18 ICUs in Australia, Japan, and Taiwan. Adult patients were consecutively screened, and those with early metabolic acidosis (pH < 7.3 and a Base Excess < -4 mEq/L, within 24-h of ICU admission) were included. Screening continued until 10 patients who received and 10 patients who did not receive sodium bicarbonate in the first 24 h (early bicarbonate therapy) were included at each site. The primary outcome was ICU mortality, and the association between sodium bicarbonate and the clinical outcomes were assessed using regression analysis with generalized linear mixed model. RESULTS: We screened 9437 patients. Of these, 1292 had early metabolic acidosis (14.0%). Early sodium bicarbonate was given to 18.0% (233/1292) of these patients. Dosing, physiological, and clinical outcome data were assessed in 360 patients. The median dose of sodium bicarbonate in the first 24 h was 110 mmol, which was not correlated with bodyweight or the severity of metabolic acidosis. Patients who received early sodium bicarbonate had higher APACHE III scores, lower pH, lower base excess, lower PaCO2, and a higher lactate and received higher doses of vasopressors. After adjusting for confounders, the early administration of sodium bicarbonate was associated with an adjusted odds ratio (aOR) of 0.85 (95% CI, 0.44 to 1.62) for ICU mortality. In patients with vasopressor dependency, early sodium bicarbonate was associated with higher mean arterial pressure at 6 h and an aOR of 0.52 (95% CI, 0.22 to 1.19) for ICU mortality. CONCLUSIONS: Early metabolic acidosis is common in critically ill patients. Early sodium bicarbonate is administered by clinicians to more severely ill patients but without correction for weight or acidosis severity. Bicarbonate therapy in acidotic vasopressor-dependent patients may be beneficial and warrants further investigation.

Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method.

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice. METHODS: Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ2) test (p < 0·05 was considered as unstable). RESULTS: Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16-24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment. CONCLUSION: Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited. TRIAL REGISTRATION: The study was registered with Clinical trials.gov Identifier: NCT04534569.

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.

'Code-95' rapid response calls for patients under airborne precautions in the COVID-19-era: a cross-sectional survey of healthcare worker perceptions.

BACKGROUND: To allow better allocation of staff and resources, rapid response teams attending to acutely deteriorating or aggressive patients with suspected or confirmed COVID-19 infection were pre-warned with the announcement of 'Code-95' with calls. AIM: To assess healthcare worker (HCW) perspectives on pre-warning rapid response calls (RRC) with 'Code-95' in announcements when attending to deteriorating or aggressive patients with suspected/confirmed COVID-19 infection. METHODS: Design: prospective cross-sectional single-centre survey of HCW over a 3-week period. SETTING: tertiary public hospital. PARTICIPANTS: HCW caring for deteriorating or aggressive patients. MAIN OUTCOME MEASURES: the primary outcome was to assess HCW perspectives in attending Code-95 calls. Secondary outcomes were to identify any differences related to craft group, age, experience or presence of comorbidities. RESULTS: A total of 297 responses was analysed; 86.7% of HCW (n = 257) attending Code-95 calls reported anxiety. Medical staff reported greater anxiety in comparison to nursing staff (93.8% vs 78.5%; P = 0.002). Efferent team reported higher anxiety in contrast to afferent team (92.6% vs 58.8%; P = 0.021). There was no significant difference in perceived anxiety based on age (≤40 vs >40 years of age), years of experience (≤5 vs >5 years), comorbidities or mental illness; 54% reported concerns about adequacy of infection-control policies and personal protective equipment; 45% were worried about inadequate training for responding to Code-95 calls. CONCLUSIONS: Most surveyed HCW supported Code-95 announcements pre-warning them of potential COVID-19 exposure when attending a RRC. However, the majority of HCW reported anxiety when attending these calls. Medical and efferent team HCW perceived greater anxiety compared to nursing and afferent team HCW. The Code-95 system to pre-warn rapid response teams may be a useful addition to protecting HCW from infectious diseases, although broader implementation will require greater resourcing, training and support.

Frailty status, timely goals of care documentation and clinical outcomes in older hospitalised medical patients.

BACKGROUND: Hospitalised frail older patients are at risk of clinical deterioration. Early goals of care (GOC) documentation is vital to avoid futile/unwarranted interventions in the event of deterioration. AIMS: To investigate the impact of frailty on timely GOC and its association with clinical outcomes in hospitalised older patients. METHODS: This was a single-centre retrospective study of all medical patients aged ≥80 years admitted to the acute medical unit between 1/3/2015 and 31/8/2015, with GOC derived from electronic records. Frailty was measured using the Hospital Frailty Risk Score (HFRS) derived from hospital coding data. Primary outcome compared proportions of timely GOC within 72-h between frail (HFRS ≥ 5) and non-frail (HFRS < 5) patients. Exploratory secondary outcomes included in-hospital mortality, rapid response calls (RRC), prolonged length of stay (LOS) and 28-day readmission rates. RESULTS: Of the 1118 admitted patients, 529 (47.3%) were frail. Timely GOC occurred in 50% (559/1118), more commonly in frail patients (283/529, 53.5%) than non-frail patients (276/589, 46.9%), P = 0.027. Frailty was positively associated with timely GOC independent of age and gender (odds ratio = 1.28; 95% confidence interval = 1.01-163; P = 0.041). In univariable analyses, timely GOC was associated with greater in-hospital mortality, RRC, and hospital LOS in both frail and non-frail patients (all P < 0.05) and greater 28-day readmissions only among frail patients (P = 0.028). Multivariable regression demonstrated that timely GOC was associated only with in-hospital mortality in both frail and non-frail patients, independent of age and gender. CONCLUSION: Older frail hospitalised patients were more likely to have timely GOC than older non-frail patients. Timely GOC in such patients may avoid burdensome treatments.

Predictors of ICU admission and long-term outcomes in overdose presentations to Emergency Department.

OBJECTIVE: To describe the characteristics of patients presenting to an Emergency Department (ED) following overdoses; to identify risk factors for intensive care unit (ICU) admission among these patients; and to identify the rate of mortality and repeat overdose presentations over four years. METHODS: Adult patients presenting to ED following drug overdose during 2014 were included. Data were collected from medical notes and hospital databases. RESULTS: During the study period, 654 patients presented to ED 800 times following overdose. Seventy-eight (9.8%) resulted in ICU admission, and 59 (7.4%) required intubation; 57.2% had no history of overdose presentations, and 72.9% involved patients with known psychiatric illness. Overdose of atypical antipsychotics (AAP), age and history of prior overdose independently predicted ICU admission. A third of patients (n = 196, 30%) had subsequent presentations to ED following overdose, in the four years from their index presentation, with an all-cause four-year mortality of 3.4% (n = 22). CONCLUSION: A history of overdose, use of AAP and older age were risk factors for ICU admission following ED presentations. Over a third of patients had repeat overdose presentation in the four-year follow-up with a mortality of 3.4%.

Prediction of ICU Delirium: Validation of Current Delirium Predictive Models in Routine Clinical Practice.

OBJECTIVES: To investigate the ability of available delirium risk assessment tools to identify patients at risk of delirium in an Australian tertiary ICU. DESIGN: Prospective observational study. SETTING: An Australian tertiary ICU. PATIENTS: All patients admitted to the study ICU between May 8, 2017, and December 31, 2017, were assessed bid for delirium throughout their ICU stay using the Confusion Assessment Method for ICU. Patients were included in this study if they remained in ICU for over 24 hours and were excluded if they were delirious on ICU admission, or if they were unable to be assessed using the Confusion Assessment Method for ICU during their ICU stay. Delirium risk was calculated for each patient using the prediction of delirium in ICU patients, early prediction of delirium in ICU patients, and Lanzhou models. Data required for delirium predictor models were obtained retrospectively from patients medical records. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 803 ICU admissions during the study period, of which 455 met inclusion criteria. 35.2% (n = 160) were Confusion Assessment Method for ICU positive during their ICU admission. Delirious patients had significantly higher Acute Physiology and Chronic Health Evaluation III scores (median, 72 vs 54; p < 0.001), longer ICU (median, 4.8 vs 1.8 d; p < 0.001) and hospital stay (16.0 vs 8.16 d; p < 0.001), greater requirement of invasive mechanical ventilation (70% vs 21.4%; p < 0.001), and increased ICU mortality (6.3% vs 2.4%; p = 0.037). All models included in this study displayed moderate to good discriminative ability. Area under the receiver operating curve for the prediction of delirium in ICU patients was 0.79 (95% CI, 0.75-0.83); recalibrated prediction of delirium in ICU patients was 0.79 (95% CI, 0.75-0.83); early prediction of delirium in ICU patients was 0.72 (95% CI, 0.67-0.77); and the Lanzhou model was 0.77 (95% CI, 0.72-0.81). CONCLUSIONS: The predictive models evaluated in this study demonstrated moderate to good discriminative ability to predict ICU patients' risk of developing delirium. Models calculated at 24-hours post-ICU admission appear to be more accurate but may have limited utility in practice.