Are we deskilling or reskilling our hospital ward clinicians?

Rapid reponse teams emerged 27 years ago to identify deteriorating patients and reduce preventable harm. There are concerns that such teams have deskilled hospital staff. However, over the past 20 years, there have been marked changes in hospital care and workplace requirements for hospital staff. In this article, we contend that hospital staff have been reskilled rather than deskilled.

Survey of hospital practitioners: common understanding of cardiopulmonary resuscitation definition and outcomes.

BACKGROUND: Cardiopulmonary resuscitation (CPR) is internationally defined as chest compressions and rescue breaths, and is a subset of resuscitation. First used for out-of-hospital cardiac arrest, CPR is now frequently used for in-hospital cardiac arrest (IHCA) with different causes and outcomes. AIMS: This paper aims to describe clinical understanding of the role of in-hospital CPR and perceived outcomes for IHCA. METHODS: An online survey of a secondary care staff involved in resuscitation was conducted, focussing on definitions of CPR, features of do-not-attempt-CPR conversations with patients and clinical case scenarios. Data were analysed using a simple descriptive approach. RESULTS: Of 652 responses, 500 were complete and used for analysis. Two hundred eleven respondents were senior medical staff covering acute medical disciplines. Ninety-one percent of respondents agreed or strongly agreed that defibrillation is part of CPR, and 96% believed CPR for IHCA included defibrillation. Responses to clinical scenarios were dissonant, with nearly half of respondents demonstrating a pattern of underestimating survival and subsequently showing a desire to offer CPR in similar scenarios with poor outcomes. This was unaffected by seniority and level of resuscitation training. CONCLUSIONS: The common use of CPR in hospital reflects the broader definition of resuscitation. Recapturing the CPR definition for clinicians and patients as only chest compressions and rescue breaths may allow clinicians to better discuss individualised resuscitation care to aide meaningful shared decision-making around patient deterioration. This may involve reframing current in-hospital algorithms and uncoupling CPR from wider resuscitative measures.

Thoracic Society of Australia and New Zealand Position Statement on Acute Oxygen Use in Adults: 'Swimming between the flags'.

Oxygen is a life-saving therapy but, when given inappropriately, may also be hazardous. Therefore, in the acute medical setting, oxygen should only be given as treatment for hypoxaemia and requires appropriate prescription, monitoring and review. This update to the Thoracic Society of Australia and New Zealand (TSANZ) guidance on acute oxygen therapy is a brief and practical resource for all healthcare workers involved with administering oxygen therapy to adults in the acute medical setting. It does not apply to intubated or paediatric patients. Recommendations are made in the following six clinical areas: assessment of hypoxaemia (including use of arterial blood gases); prescription of oxygen; peripheral oxygen saturation targets; delivery, including non-invasive ventilation and humidified high-flow nasal cannulae; the significance of high oxygen requirements; and acute hypercapnic respiratory failure. There are three sections which provide (1) a brief summary, (2) recommendations in detail with practice points and (3) a detailed explanation of the reasoning and evidence behind the recommendations. It is anticipated that these recommendations will be disseminated widely in structured programmes across Australia and New Zealand.

End-of-life priorities of older adults with terminal illness and caregivers: A qualitative consultation.

BACKGROUND: As older adults approach the end-of-life (EOL), many are faced with complex decisions including whether to use medical advances to prolong life. Limited information exists on the priorities of older adults at the EOL. OBJECTIVE: This study aimed to explore patient and family experiences and identify factors deemed important to quality EOL care. METHOD: A descriptive qualitative study involving three focus group discussions (n = 18) and six in-depth interviews with older adults suffering from either a terminal condition and/or caregivers were conducted in NSW, Australia. Data were analysed thematically. RESULTS: Seven major themes were identified as follows: quality as a priority, sense of control, life on hold, need for health system support, being at home, talking about death and competent and caring health professionals. An underpinning priority throughout the seven themes was knowing and adhering to patient's wishes. CONCLUSION: Our study highlights that to better adhere to EOL patient's wishes a reorganization of care needs is required. The readiness of the health system to cater for this expectation is questionable as real choices may not be available in acute hospital settings. With an ageing population, a reorganization of care which influences the way we manage terminal patients is required.

Effect of 0.9% Saline or Plasma-Lyte 148 as Crystalloid Fluid Therapy in the Intensive Care Unit on Blood Product Use and Postoperative Bleeding After Cardiac Surgery.

OBJECTIVE: To evaluate the effect of Plasma-Lyte 148 (PL-148) compared with 0.9% saline (saline) on blood product use and postoperative bleeding in patients admitted to the intensive care unit (ICU) following cardiac surgery. DESIGN: A post hoc subgroup analysis conducted within a multicenter, double-blind, cluster-randomized, double-crossover study (study 1) and a prospective, single-center nested-cohort study (study 2). SETTING: Tertiary-care hospitals. PARTICIPANTS: Adults admitted to the ICU after cardiac surgery requiring crystalloid fluid therapy as part of the 0.9% saline vs. PL-148 for ICU fluid therapy (SPLIT) trial. INTERVENTIONS: Blinded saline or PL-148 for 4 alternating 7-week blocks. MEASUREMENTS AND MAIN RESULTS: 954 patients were included in study 1; 475 patients received PL-148, and 479 received saline. 128 of 475 patients (26.9%) in the PL-148 group received blood or a blood product compared with 94 of 479 patients (19.6%) in the saline group (OR [95% confidence interval], 1.51 [1.11-2.05]; p = 0.008). In study 2, 131 patients were allocated to PL-148 and 120 patients were allocated to saline. There were no differences between groups in chest drain output from the time of arrival in the ICU until 12 hours postoperatively (geometric mean, 566 mL for the PL-148 group v 547 mL in the saline group; p = 0.60). CONCLUSIONS: The findings did not support the hypothesis that using PL-148 for fluid therapy in ICU following cardiac surgery reduces transfusion requirements compared to saline. The significantly increased proportion of patients receiving blood or blood product with allocation to PL-148 compared to saline was unexpected and requires verification through further research.

Models and activities of critical care outreach in New Zealand hospitals: results of a national census.

AIM: To review clinical models and activities of critical care outreach (CCO) in New Zealand public hospitals. METHODS: Data were collected using a two-stage process. Stage 1 consisted of a cross-sectional descriptive online survey distributed to nurse managers of all CCO in New Zealand. Stage 2 requested that all respondent sites supply outreach documentation for analysis. RESULTS: Twenty acute care public hospitals replied to the data request (100%). Nine hospitals (45%) had CCO and completed the survey. There was considerable diversity in the models of CCO used. All nine hospitals had CCO that were nurse-led; 66% of these had intensive care medical input. There was variation in the size and scope of each CCO with only 4 (44%) sites providing 24-h clinical cover. The majority of referral requests made to CCO were for ward-based reviews (mean: 57%) and intensive care discharge reviews (mean: 31%). The most frequently performed activity was provision of support to ward staff (89%). All CCO routinely collected data on activities across a range of clinical areas. CONCLUSION: Less than half of the public hospitals in New Zealand have a CCO service despite national recommendations that every hospital utilize one to support deteriorating ward patients. New Zealand hospitals that have critical care outreach have adopted recognized international models and adapted these to meet local demands. Whilst the evidence base demonstrating impact of critical care outreach continues to be established, international support for critical care outreach continues. Given this, critical care outreach should be more widely available 24/7 and activities standardized across New Zealand to align with national recommendations. RELEVANCE TO CLINICAL PRACTICE: Critical care outreach service models and activities in New Zealand hospitals continue to be diverse. Awareness of these variances will help influence critical care outreach service development and regional integration.

Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit: The SPLIT Randomized Clinical Trial.

IMPORTANCE: Saline (0.9% sodium chloride) is the most commonly administered intravenous fluid; however, its use may be associated with acute kidney injury (AKI) and increased mortality. OBJECTIVE: To determine the effect of a buffered crystalloid compared with saline on renal complications in patients admitted to the intensive care unit (ICU). DESIGN AND SETTING: Double-blind, cluster randomized, double-crossover trial conducted in 4 ICUs in New Zealand from April 2014 through October 2014. Three ICUs were general medical and surgical ICUs; 1 ICU had a predominance of cardiothoracic and vascular surgical patients. PARTICIPANTS: All patients admitted to the ICU requiring crystalloid fluid therapy were eligible for inclusion. Patients with established AKI requiring renal replacement therapy (RRT) were excluded. All 2278 eligible patients were enrolled; 1152 of 1162 patients (99.1%) receiving buffered crystalloid and 1110 of 1116 patients (99.5%) receiving saline were analyzed. INTERVENTIONS: Participating ICUs were assigned a masked study fluid, either saline or a buffered crystalloid, for alternating 7-week treatment blocks. Two ICUs commenced using 1 fluid and the other 2 commenced using the alternative fluid. Two crossovers occurred so that each ICU used each fluid twice over the 28 weeks of the study. The treating clinician determined the rate and frequency of fluid administration. MAIN OUTCOMES AND MEASURES: The primary outcome was proportion of patients with AKI (defined as a rise in serum creatinine level of at least 2-fold or a serum creatinine level of ≥3.96 mg/dL with an increase of ≥0.5 mg/dL); main secondary outcomes were incidence of RRT use and in-hospital mortality. RESULTS: In the buffered crystalloid group, 102 of 1067 patients (9.6%) developed AKI within 90 days after enrollment compared with 94 of 1025 patients (9.2%) in the saline group (absolute difference, 0.4% [95% CI, -2.1% to 2.9%]; relative risk [RR], 1.04 [95% CI, 0.80 to 1.36]; P = .77). In the buffered crystalloid group, RRT was used in 38 of 1152 patients (3.3%) compared with 38 of 1110 patients (3.4%) in the saline group (absolute difference, -0.1% [95% CI, -1.6% to 1.4%]; RR, 0.96 [95% CI, 0.62 to 1.50]; P = .91). Overall, 87 of 1152 patients (7.6%) in the buffered crystalloid group and 95 of 1110 patients (8.6%) in the saline group died in the hospital (absolute difference, -1.0% [95% CI, -3.3% to 1.2%]; RR, 0.88 [95% CI, 0.67 to 1.17]; P = .40). CONCLUSIONS AND RELEVANCE: Among patients receiving crystalloid fluid therapy in the ICU, use of a buffered crystalloid compared with saline did not reduce the risk of AKI. Further large randomized clinical trials are needed to assess efficacy in higher-risk populations and to measure clinical outcomes such as mortality. TRIAL REGISTRATION: clinicaltrials.gov Identifier: ACTRN12613001370796.

Framework for decision-making and management of end-of-life decisions in Intensive Care Units: A modified protocol.

End-of-life decisions are being made daily in Intensive Care Units worldwide. The spectrum of options varies from full-continued care, withholding treatment, withdrawing treatment, and active life-ending procedures depending on the institutional practices and legal framework. Considering the complexity of the situation and the legalities involved, it is important to have a structured approach toward these sensitive decisions. It does make sense to have a protocol that ensures proper documentation and helps ease the physicians involved in such decisions. Clear documentation in the format of a checklist would ensure consistency and help the entire medical team to be uniformly informed about the end-of-life plan.

Rethinking resuscitation: moving the goals.

Cardiopulmonary resuscitation (CPR) techniques have developed remarkably since first described. CPR is now both a default treatment and a public expectation. However, anticipated outcomes are not matched by reality. The differences between in- and out-of-hospital cardiac arrests are often not recognised and almost never taught. 'Do Not Resuscitate' orders developed to provide the ability to opt-out of this treatment. Nevertheless, CPR is still inappropriately used in settings where reversibility and likelihood of benefit are not meaningfully considered or discussed with the patient. Further, treatment escalation is a continuum, so resuscitation orders present a false dichotomy of 'do' or 'do not' resuscitate. Asking patients about their goals, and only offering treatments aligned with those goals, allows consideration of the burden of treatment and the likelihood of success. Shared decision models improve communication and patient autonomy. Tools are available to help clinicians with the difficult conversation and document the outcomes. Now, in both our training and practice, it is time to move beyond the stark and often irrelevant choice between CPR and 'Not for Resuscitation'.

A catalogue of tools and variables from crisis and routine care to support decision-making about allocation of intensive care beds and ventilator treatment during pandemics: Scoping review.

PURPOSE: This scoping review sought to identify objective factors to assist clinicians and policy-makers in making consistent, objective and ethically sound decisions about resource allocation when healthcare rationing is inevitable. MATERIALS AND METHODS: Review of guidelines and tools used in ICUs, hospital wards and emergency departments on how to best allocate intensive care beds and ventilators either during routine care or developed during previous epidemics, and association with patient outcomes during and after hospitalisation. RESULTS: Eighty publications from 20 countries reporting accuracy or validity of prognostic tools/algorithms, or significant correlation between prognostic variables and clinical outcomes met our eligibility criteria: twelve pandemic guidelines/triage protocols/consensus statements, twenty-two pandemic algorithms, and 46 prognostic tools/variables from non-crisis situations. Prognostic indicators presented here can be combined to create locally-relevant triage algorithms for clinicians and policy makers deciding about allocation of ICU beds and ventilators during a pandemic. No consensus was found on the ethical issues to incorporate in the decision to admit or triage out of intensive care. CONCLUSIONS: This review provides a unique reference intended as a discussion starter for clinicians and policy makers to consider formalising an objective a locally-relevant triage consensus document that enhances confidence in decision-making during healthcare rationing of critical care and ventilator resources.

Unplanned admissions to the Wellington Hospital intensive care unit before, during and after New Zealand's COVID-19 lockdown.

AIM: To evaluate rates of unplanned ICU admissions before, during and after New Zealand's COVID-19 Alert Level 4/3 lockdown, and to describe the characteristics and outcomes of patients admitted to Wellington ICU during lockdown in comparison to historical controls. METHOD: We conducted a retrospective cohort study using the Wellington Hospital ICU database and included patients with an unplanned ICU admission during the first 35 weeks of the year from 2015 to 2020 inclusive. The primary variable of interest was the rate of unplanned ICU admission in 2020 compared with historical controls. We also described the characteristics and outcomes of patients with unplanned admissions to ICU during the 2020 COVID-19 lockdown compared to historical controls. RESULTS: During the five weeks of Alert Level Four, and the subsequent two weeks of Alert Level Three, the number of unplanned ICU admissions per day fell to 1.65±1.52 compared to a historical average of 2.56±1.52 ICU unplanned ICU admissions per day (P<0.0001). The observed reduction in ICU admission rates appeared to occur for most categories of ICU admission diagnosis but was not evident for patients with neurologic disorders. The characteristics and outcomes of patients who had unplanned admissions to Wellington ICU during the COVID-19 lockdown were broadly similar to historical controls. The rate of unplanned ICU admissions in 2020 before and after the lockdown period were similar to historical controls. CONCLUSION: In this study, we observed a reduction in unplanned admissions to Wellington Hospital ICU associated with New Zealand's initial COVID-19 lockdown.

Appropriateness of intensive care treatments near the end of life during the COVID-19 pandemic.

The patient and family perspective on the appropriateness of intensive care unit (ICU) treatments involves preferences, values and social constructs beyond medical criteria. The clinician's perception of inappropriateness is more reliant on clinical judgment. Earlier consultation with families before ICU admission and patient education on the outcomes of life-sustaining therapies may help reconcile these provider-patient disagreements. However, global emergencies like COVID-19 change the usual paradigm of end-of-life care, as it is a new disease with only scarce predictive information about it. Pandemics can also bring about the burdensome predicament of doctors having to make unwanted choices of rationing access to the ICU when demand for otherwise life-saving resources exceeds supply. Evidence-based prognostic checklists may guide treatment triage but the principles of shared decision-making are unchanged. Yet, they need to be altered with respect to COVID-19, defining likely outcomes and likelihood of benefit for the patient, and clarifying their willingness to take on the risks inherent to being in an ICU for 2 weeks for those eligible. For patients who are admitted during the prodrome of COVID-19 disease, or those who deteriorate in the second week, clinicians have some lead time in hospital to have appropriate discussions about ceilings of treatments offered based on severity. KEY POINTS: The patient and family perspective on inappropriateness of intensive care at the end of life often differs from the clinician's opinion due to the nonmedical frame of mind.To improve satisfaction with communication on treatment goals, consultation on patient values and inclusion of social constructs in addition to clinical prediction is a good start to reconcile differences between physician and health service users' viewpoints.During pandemics, where health systems may collapse, different admission criteria driven by the need to ration services may be warranted. EDUCATIONAL AIMS: To explore the extent to which older patients and their families are involved in decisions about appropriateness of intensive care admission or treatmentsTo understand how patients or their families define inappropriate intensive care admission or treatmentsTo reflect on the implications of decision to admit or not to admit to the intensive care unit in the face of acute resource shortages during a pandemic.

Comparison of cough reflex testing with videoendoscopy in recently extubated intensive care unit patients.

PURPOSE: Orotracheal intubation is known to impair cough reflex, but the validity of cough reflex testing (CRT) as a screening tool for silent aspiration in this population is unknown. MATERIAL AND METHODS: One hundred and six participants in a tertiary-level intensive care unit (ICU) underwent CRT and videoendoscopic evaluation of swallowing (VES) within 24 hours of extubation. Cough reflex threshold was established for each participant using nebulized citric acid. RESULTS: Thirty-nine (37%) participants had an absent cough to CRT. Thirteen (12%) participants aspirated on VES, 9 (69%) without a cough response. Sensitivity of CRT to identify silent aspiration was excellent, but specificity was poor. There was a significant correlation between intubation duration and presence of aspiration on VES (P= .0107). There was no significant correlation between silent aspiration on VES and length of intubation, age, sex, diagnosis at intensive care unit admission, indication for intubation, Acute Physiology and Chronic Health Evaluation III score, morphine equivalent dose, or time of testing postextubation. CONCLUSIONS: Intensive care unit patients are at increased risk of aspiration in the 24 hours following extubation, and an impaired cough reflex is common. However, CRT overidentifies risk of silent aspiration in this population.

Non-technical skills evaluation in the critical care air ambulance environment: introduction of an adapted rating instrument--an observational study.

BACKGROUND: In the isolated and dynamic health-care setting of critical care air ambulance transport, the quality of clinical care is strongly influenced by non-technical skills such as anticipating, recognising and understanding, decision making, and teamwork. However there are no published reports identifying or applying a non-technical skills framework specific to an intensive care air ambulance setting. The objective of this study was to adapt and evaluate a non-technical skills rating framework for the air ambulance clinical environment. METHODS: In the first phase of the project the anaesthetists' non-technical skills (ANTS) framework was adapted to the air ambulance setting, using data collected directly from clinician groups, published literature, and field observation. In the second phase experienced and inexperienced inter-hospital transport clinicians completed a simulated critical care air transport scenario, and their non-technical skills performance was independently rated by two blinded assessors. Observed and self-rated general clinical performance ratings were also collected. Rank-based statistical tests were used to examine differences in the performance of experienced and inexperienced clinicians, and relationships between different assessment approaches and assessors. RESULTS: The framework developed during phase one was referred to as an aeromedical non-technical skills framework, or AeroNOTS. During phase two 16 physicians from speciality training programmes in intensive care, emergency medicine and anaesthesia took part in the clinical simulation study. Clinicians with inter-hospital transport experience performed more highly than those without experience, according to both AeroNOTS non-technical skills ratings (p = 0.001) and general performance ratings (p = 0.003). Self-ratings did not distinguish experienced from inexperienced transport clinicians (p = 0.32) and were not strongly associated with either observed general performance (r(s) = 0.4, p = 0.11) or observed non-technical skills performance (r(s) = 0.4, p = 0.1). DISCUSSION: This study describes a framework which characterises the non-technical skills required by critical care air ambulance clinicians, and distinguishes higher and lower levels of performance. CONCLUSION: The AeroNOTS framework could be used to facilitate education and training in non-technical skills for air ambulance clinicians, and further evaluation of this rating system is merited.

Effect of saline 0.9% or Plasma-Lyte 148 therapy on feeding intolerance in patients receiving nasogastric enteral nutrition.

OBJECTIVE: To compare the effect of Plasma-Lyte (PL)-148 and saline 0.9% (saline) on gastrointestinal (GI) feeding intolerance in mechanically ventilated patients receiving nasogastric (NG) feeding in an intensive care unit. DESIGN AND SETTING: A single-centre pilot study, nested within a multicentre, double-blind, cluster-randomised, double-crossover trial, performed in a mixed medical and surgical ICU. PARTICIPANTS: All adult patients who required crystalloid fluid therapy as part of the 0.9% Saline versus Plasma-Lyte 148 for Intensive Care Unit Fluid Therapy (SPLIT) trial, were expected to need mechanical ventilation for more than 48 hours and were receiving enteral nutrition exclusively by NG tube were eligible. We enrolled 69 patients and assigned 35 to PL-148 and 34 to saline. INTERVENTIONS: We randomly allocated saline or PL-148 for four alternating 7-week blocks, with staff blinded to the solution. MAIN OUTCOME MEASURES: The primary outcome was the proportion of patients with GI feeding intolerance, defined as high gastric residual volume (GRV), diarrhoea or vomiting while receiving NG feeding in the ICU. The proportions of patients with each of high GRV, diarrhoea and vomiting were secondary outcomes. RESULTS: In the PL-148 group, 21 of 35 patients (60.0%) developed GI feeding intolerance, compared with 22 of 34 patients (64.7%) in the saline group (odds ratio [OR], 0.82; 95% CI, 0.31-2.17; P = 0.69). A high GRV was seen in four of 35 patients (11.4%) in the PL-148 group, and in 11 of 34 patients (32.4%) in the saline group (OR, 0.27; 95% CI, 0.08-0.96; P = 0.04). CONCLUSION: Among mechanically ventilated patients receiving NG feeding, the use of PL-148, compared with saline, did not reduce the proportion of patients developing GI feeding intolerance, but was associated with a decreased incidence of high GRV.

Participant perceptions of a rapid response team training course.

BACKGROUND: Rapid response team (RRT) responders would benefit from training, to ensure competent and efficient management of the deteriorating patient. DESIGN, SETTING AND PARTICIPANTS: We obtained delegate feedback on a pilot training course for RRTs, commissioned by the Australian and New Zealand Intensive Care Society (ANZICS), at the second ANZICS: The Deteriorating Patient Conference. METHODS: We surveyed participants on their perceptions of the course overall, and their perceptions of sessions containing presentations and videotaped and live demonstrations of simulated scenarios of patients whose conditions were deteriorating. RESULTS: The survey response rate was 64% (96 of 150 potential attendees). Responses were positive, with 79.8% of responses (912/1143) agreeing that the participants had learnt something new, that the course would increase their confidence and competence during RRT calls, and that it had assisted them as an educator. The course was well received overall, with the interactive and live demonstration components of the course garnering positive feedback in the comments section of surveys. CONCLUSIONS: There was unanimous agreement by participants for further development of a formalised RRT training course for responding to the deteriorating patient. Participants who were RRT educators also supported the development of an RRT train-the-trainer course.

Recovery of cough after extubation after coronary artery bypass grafting: A prospective study.

PURPOSE: This study aims to evaluate the effect of intubation for coronary artery bypass grafting (CABG) on the cough reflex, an important airway protection mechanism. MATERIALS: Eighty-six participants (70 males) underwent cough reflex texting (CRT) before intubation for CABG to establish baseline threshold for reflexive cough. Cough reflex texting was repeated within 2 hours of extubation and every morning and evening thereafter until the participant coughed at baseline level, withdrew, or was discharged from hospital. RESULTS: Sixty percent of participants had an absent cough reflex at CRT2 (x = 70 minutes). Participants varied in time to recovery of cough reflex. By CRT6, only 3 remaining participants persisted with an absent cough. Age, sex, or length of intubation had no significant impact on the time to recovery of cough reflex (P > .3). CONCLUSIONS: Absent cough reflex persists after CABG and may impact patients' ability to clear their airway in the event of aspiration. These results could contribute to better understanding postextubation dysphagia. More research is needed to determine if cough reflex is affected in the wider intensive care unit population postextubation and if CRT is a valid tool for detecting silent aspiration in this population.