A survey of Australian public opinion on using comorbidity to triage intensive care patients in a pandemic.

ObjectivesThis study aimed to determine which method to triage intensive care patients using chronic comorbidity in a pandemic was perceived to be the fairest by the general public. Secondary objectives were to determine whether the public perceived it fair to provide preferential intensive care triage to vulnerable or disadvantaged people, and frontline healthcare workers.MethodsA postal survey of 2000 registered voters randomly selected from the Australian Electoral Commission electoral roll was performed. The main outcome measures were respondents' fairness rating of four hypothetical intensive care triage methods that assess comorbidity (chronic medical conditions, long-term survival, function and frailty); and respondents' fairness rating of providing preferential triage to vulnerable or disadvantaged people, and frontline healthcare workers.ResultsThe proportion of respondents who considered it fair to triage based on chronic medical conditions, long-term survival, function and frailty, was 52.1, 56.1, 65.0 and 62.4%, respectively. The proportion of respondents who considered it unfair to triage based on these four comorbidities was 31.9, 30.9, 23.8 and 23.2%, respectively. More respondents considered it unfair to preferentially triage vulnerable or disadvantaged people, than fair (41.8% versus 21.2%). More respondents considered it fair to preferentially triage frontline healthcare workers, than unfair (44.2% versus 30.0%).ConclusionRespondents in this survey perceived all four hypothetical methods to triage intensive care patients based on comorbidity in a pandemic disaster to be fair. However, the sizable minority who consider this to be unfair indicates that these triage methods could encounter significant opposition if they were to be enacted in health policy.

Diabetes and hyperglycaemia among hospitalised patients with COVID-19 in Western Sydney: a retrospective cohort study.

BACKGROUND: Diabetes has been recognised as a major risk factor for COVID-19 mortality and hospital complications in earlier studies. AIMS: To examine the characteristics of hospitalised COVID-19 patients with diabetes and the impact of diabetes and hyperglycaemia on hospital outcomes. METHODS: This was a retrospective cohort study. Admission glucose levels, HbA1c, diabetes status and hospital outcomes were determined for subjects admitted from June to November 2021 by matching a pathology data set, a clinical data set and the hospital administrative database. The outcomes of interest were death, intensive care unit (ICU) admission and length of stay (LOS). RESULTS: There were 1515 individuals admitted with COVID-19 with 49 deaths (3.2%) and 205 (13.5%) ICU admissions. The median length of hospital stay was 3.7 days. Three hundred and ten patients (20%) had diabetes, with 46 (15%) newly diagnosed. Patients with diabetes had a higher mortality than patients who did not have diabetes (8% vs 2%, P < 0.001), were more likely to be admitted to ICU (20% vs 12%, P = 0.001) and have longer median LOS stay (6.6 (interquartile range (IQR) 2.9-12.5) vs 2.9 (IQR 0.5-7.1) days, P < 0.001). In multivariate models, neither diabetes nor admission glucose predicted death. Admission glucose level but not diabetes was an independent predictor of ICU admission and LOS. CONCLUSIONS: There is a high prevalence of diabetes among patients hospitalised with COVID-19, with worse outcomes. In contrast to previous studies, the association of diabetes with mortality was not significant when adjusted for other variables. This is possibly related to the benefits of vaccination and current medical and ICU interventions.

Introducing 1,3-beta-d-glucan for screening and diagnosis of invasive fungal diseases in Australian high-risk haematology patients: is there a clinical benefit?

BACKGROUND: Early, accurate diagnosis of invasive fungal disease (IFD) improves clinical outcomes. 1,3-beta-d-glucan (BDG) (Fungitell, Associates of Cape Cod, Inc., Falmouth, MA, USA) detection can improve IFD diagnosis but has been unavailable in Australia. AIMS: To assess performance of serum BDG for IFD diagnosis in a high-risk Australian haematology population. METHODS: We compared the diagnostic value of weekly screening of serum BDG with screening by Aspergillus polymerase chain reaction and Aspergillus galactomannan in 57 at-risk episodes for the diagnosis of IFD (proven, probable, possible IFD). RESULTS: IFD episodes were: proven (n = 4); probable (n = 4); possible (n = 18); and no IFD (n = 31). Using two consecutive BDG results of ≥80 pg/mL to call a result 'positive', the sensitivity, specificity, positive predictive value and negative predictive value was 37.5%, 64.5%, 23.1% and 80.7% respectively. For invasive aspergillosis, test performance increased to 50%, 90.3%, 57.1% and 87.5% respectively if any two of serum BDG/Aspergillus polymerase chain reaction/galactomannan yielded a 'positive' result. In proven/probable IFD, five of eight episodes returned a positive BDG result earlier (mean 6.6 days) than other diagnostic tests. False-negative BDG results occurred in three of eight episodes of proven/probable IFD, and false positive in 10 of 31 patients with no IFD. Erratic patterns of BDG values predicted false positive results (P = 0.03). Using serum BDG results, possible IFD were reassigned to either 'no' or 'probable' IFD in 44% cases. Empiric anti-fungal therapy use may have been optimised by BDG monitoring in 38.5% of courses. CONCLUSIONS: The BDG assay can add diagnostic speed and value but was hampered by low sensitivity and positive predictive value in Australian haematology patients.

Short research paper: Personal protective equipment for the care of suspected and confirmed COVID-19 patients - Modelling requirements and burn rate.

BACKGROUND: The COVID-19 pandemic has caused unprecedented global demand for personal protective equipment (PPE). A paucity of data on PPE burn rate (PPE consumption over time) in pandemic situations exacerbated these issues as there was little historic research to indicate volumes of PPE required to care for surges in infective patients and thus plan procurement requirements. METHODS: To better understand PPE requirements for care of suspected or confirmed COVID-19 patients in our Australian quaternary referral hospital, the number of staff-to-patient interactions in a 24-h period for three patient groups (ward-based COVID suspect, ward-based COVID confirmed, intensive care COVID confirmed) was audited prospectively from 1st to 30th April 2020. RESULTS: The average number of staff-to-patient interactions in a 24-h period was: 13.1 ± 5.0 (mean ± SD) for stable ward-managed COVID-19 suspect patients; 11.9 ± 3.8 for stable ward-managed confirmed COVID-19 patients; and 30.0 ± 5.3 for stable, mechanically ventilated, ICU-managed COVID-19 patients. This data can be used in PPE demand simulation modelling for COVID-19 and potentially other respiratory illnesses. CONCLUSION: Data on the average number of staff-to-patient interactions needed for the care of COVID-19 patients is presented. This data can be used for PPE demand simulation modelling.

Third generation cephalosporins and piperacillin/tazobactam have distinct impacts on the microbiota of critically ill patients.

Effective implementation of antibiotic stewardship, especially in critical care, is limited by a lack of direct comparative investigations on how different antibiotics impact the microbiota and antibiotic resistance rates. We investigated the impact of two commonly used antibiotics, third-generation cephalosporins (3GC) and piperacillin/tazobactam (TZP) on the endotracheal, perineal and faecal microbiota of intensive care patients in Australia. Patients exposed to either 3GC, TZP, or no ß-lactams (control group) were sampled over time and 16S rRNA amplicon sequencing was performed to examine microbiota diversity and composition. While neither treatment significantly affected diversity, numerous changes to microbiota composition were associated with each treatment. The shifts in microbiota composition associated with 3GC exposure differed from those observed with TZP, consistent with previous reports in animal models. This included a significant increase in Enterobacteriaceae and Enterococcaceae abundance in endotracheal and perineal microbiota for those administered 3GC compared to the control group. Culture-based analyses did not identify any significant changes in the prevalence of specific pathogenic or antibiotic-resistant bacteria. Exposure to clinical antibiotics has previously been linked to reduced microbiota diversity and increased antimicrobial resistance, but our results indicate that these effects may not be immediately apparent after short-term real-world exposures.

An observational study on the practice of noninvasive ventilation at a tertiary level Australian intensive care unit.

BACKGROUND: Failure of Non-Invasive Ventilation (NIV) is associated with increased morbidity and mortality among critically ill patients. Although there is evidence of association between disease related factors and NIV failure, it is unclear whether factors related to NIV application contribute to NIV failure. OBJECTIVES: To evaluate NIV failure rate and factors associated with NIV failure. DESIGN, SETTINGS AND OUTCOMES: Prospective, observational, pilot study conducted in a 23-bed, tertiary care Intensive Care Unit (ICU). NIV failure was defined as application of NIV resulting in intubation or death in ICU. RESULTS: Amongst 238 patients admitted with respiratory failure, NIV was administered to 60 patients (34 males, 26 females) for a total of 70 application episodes. The etiology of respiratory failure included acute pulmonary edema (28.6%), acute lung injury (22.9%) and pneumonia (15.7%). The mean (SD) age was 62 (17.6) years, BMI 32.0 (8.5) kg/m2 and median APACHE-II score 17.5 (14.0-23.8). NIV failure occurred in 22 out of 70 applications (31.4% [95%CI 20.0-43.0]). NIV failure assessed by simple logistic regression analysis, was associated with admission diagnosis (OR 6.0, 95%CI: 1.3-28.7, p = 0.03), use of bi-level NIV-PS (OR 5.00, 95%CI: 1.04-24.1, p = 0.04), presence of nasogastric tube (OR 6.20, 95%CI: 1.9-19.8, p < 0.01) and with short NIV breaks in the 2nd 24-hours (OR 0.96, 95%CI: 0.91-0.99, p = 0.04). CONCLUSION: NIV failure was observed in 31.4%. Factors associated with NIV failure were etiology of respiratory illness, type of NIV support and short NIV breaks, presumably reflecting illness severity or progress of disease. The presence of a nasogastric tube during application of NIV may adversely impact NIV application.

Ethical considerations in the management of Ebola virus disease.

Is it ethically appropriate in some circumstances for HCWs to decline to care for patients with EVD? How should treatment decisions be made regarding limitation of therapy for patients with EVD? There are two main ethical questions regarding the critical care of patients with EVD in an Australian setting: Is it ethically appropriate in some circumstances for HCWs to decline to care for patients with EVD? How should treatment decisions be made regarding limitation of therapy for patients with EVD? The key concern is ensuring that no patient is denied therapy that should be provided, while preventing unnecessary risk to HCWs. It is imperative to develop an approach that facilitates rigorous, evidence-based and ethically justifiable decision making, which should include a predetermined, institutionally endorsed process for assessing difficult clinical scenarios as they arise.

Evaluation of point-of-care testing in critically unwell patients: comparison with clinical laboratory analysers and applicability to patients with Ebolavirus infection.

Data on the performance of point-of-care (POC) or near-patient devices in the management of critically unwell patients are limited, meaning that there are demands for confirming POC test results in the routine clinical laboratory and so potentially leading to delay in treatment provision. We evaluated the performance of the i-STAT CHEM 8+ and CG4+, Hemochron Signature Elite, HemoCue Hb 201+ and WBC Diff Systems on whole blood collected from medical and surgical patients admitted to the intensive care unit at an Australian tertiary care hospital. Measurements obtained for haematology, coagulation, biochemistry and arterial blood gas parameters using POC devices were compared against clinical laboratory analysers (XE-5000, STA-R Evolution, Dimension Vista 1500 and ABL800 FLEX). Bland-Altman and Passing-Bablok regression plots were constructed to assess agreement. Good correlation was defined as a bias of <10% between the POC device and the reference method. Forty arterial blood samples were collected from 28 patients. There was good correlation demonstrated for sodium, potassium, chloride, ionised calcium, glucose, urea, haemoglobin and haematocrit values (i-STAT Chem 8+); pH, pCO(2), bicarbonate and oxygen saturation (i-STAT CG4+); haemoglobin, white cell, neutrophil count and lymphocyte counts (Hemocue); and internationalised normal ratio (INR; Hemochron Signature Elite), but not creatinine, anion gap, pO(2), base excess, lactate, eosinophil count, prothrombin and activated partial thromboplastin time. POC devices were comparable to clinical laboratory analysers in measuring the majority of haematology, biochemistry and coagulation parameters in critically unwell patients, including those with infections. These devices may be deployed at the bedside to allow 'real-time' testing to improve patient care.

Immediate coronary angiogram in comatose survivors of out-of-hospital cardiac arrest--an Australian study.

INTRODUCTION: The role of immediate coronary angiography and percutaneous coronary intervention (angio±PCI), amongst comatose survivors of out-of-hospital cardiac arrest is unclear. This study was undertaken to evaluate if immediate angio±PCI compared to no initial intervention improves neurological outcome at hospital discharge amongst comatose survivors of out-of-hospital pulseless ventricular tachycardia (pVT) or ventricular fibrillation (VF). METHODS: All patients admitted to Intensive Care Unit (ICU) following an out-of-hospital VF/pVT arrest from 1/1/2003 to 31/12/2008 were included. Outcome of patients who underwent immediate angio±PCI was compared to those who did not undergo any intervention before admission to ICU. Good outcome was defined as survival to hospital discharge with Cerebral Performance Category (CPC) score of 1 or 2. RESULTS: Thirty-five patients (30 Males, 5 Females, mean age 60.3±10.1), underwent angio±PCI prior to ICU admission. A further 35 patients (20 Males, 15 Females, mean age 61.1±17.6 years) were admitted directly to ICU without undergoing any intervention. Forty percent (14/35) of patients who had immediate coronary intervention survived to hospital discharge with a good outcome compared to 31% (11/35) patients who did not undergo any intervention. After adjusting for other covariates, the probability of good outcome at hospital discharge was related to severity of illness (SAPS-II) score at ICU admission (adj OR=0.87, 95% CI 0.81-0.94, p<0.01). Immediate angio±PCI compared to no intervention was associated with an improved outcome but this difference was statistically not significant (adj OR 1.32, 95% CI 0.26-7.87, p=0.78). CONCLUSION: Immediate angio±PCI in comatose survivors of out-of-hospital VF/pVT arrest did not lead to better neurological outcome at hospital discharge.

Rapid response systems: a prospective study of response times.

PURPOSE: The purpose of the study was to evaluate the time taken for delivery of each component of care following patient deterioration and to assess the effect on response times of strategies implemented to improve the system. METHODS: A model identifying the sequence of organizational responses following a patient's unexpected clinical deterioration was developed. The time to key events and interventions from initial deterioration was measured for 3 months in 2005 and again in 2006 at a tertiary care hospital with a rapid response team (RRT) in place. Strategies to improve compliance with the RRT system were introduced between the 2 periods. RESULTS: The number of acute deterioration episodes identified increased (61 episodes in 2005; 154 episodes in 2006), but there was no improvement in response times. The 2 components contributing most frequently to delays were the time for nursing staff to call for assistance and, where needed, for physicians to call for higher-level care. Overall, 26% of episodes in 2006 and 30% in 2005 did not receive medical attention within 30 minutes of acute deterioration. CONCLUSIONS: Significant delays in responding to acute deterioration persist despite strategies to facilitate the functioning of the RRT system. Simple strategies such as policy directives are not sufficient to effect change in complex health care systems.

Does after-hours discharge of ICU patients influence outcome?

OBJECTIVE: To assess the frequency of after-hours discharges of patients from the intensive care unit and its effect on in-hospital mortality. DESIGN, SETTING AND PARTICIPANTS: Observational cohort study conducted in the ICU of Westmead Hospital, a tertiary care teaching hospital in Sydney. All adult patients admitted to the ICU between 1 January 2004 and 31 December 2006 were included in the study cohort. Patients were grouped into two categories based on the time of discharge from the ICU: during work hours (08:00-17:59 hours) or after-hours (18:00-07:59 hours). MAIN OUTCOME MEASURE: Mortality after discharge from the ICU according to time of discharge. MEASUREMENTS AND MAIN RESULTS: 2300 patients accounted for 2451 admission episodes during the study period. There were 151 readmissions, involving 133 patients (5.8%). Excluded from the study cohort were 36 patients (1.6%) who were discharged home, 39 (1.7%) who were transferred to other hospitals, and 354 (15.4%) who died during their first stay in the ICU. Data on the remaining 1871 patients who were discharged alive at the end of their first ICU admission were included in our analysis. Of these patients, 1221 (65.3%) were discharged from the ICU during work-hours and 650 (34.7%) after-hours. Crude mortality for patients discharged after-hours was 13.7%, compared with 10.1% for those discharged during work hours. After adjustment for age, APACHE II score and discharge destination, the risk of mortality among patients discharged after-hours was statistically significant (adjusted odds ratio, 1.38 [95% CI, 1.01-1.88]; P < 0.05). CONCLUSIONS: A high proportion of patients (34.7%) were discharged from the ICU after-hours. Discharge after-hours was associated with a higher risk of in-hospital mortality than discharge during work hours.

Do men and women differ in their course following traumatic brain injury? A preliminary prospective investigation of early outcome.

PRIMARY OBJECTIVE: To examine the effect of a patient's sex on measures of outcome in a matched sample of patients admitted for acute traumatic brain injury (TBI). RESEARCH DESIGN: A prospective multi-centred group comparison study based in metropolitan Sydney, Australia. METHODS AND PROCEDURES: Data was collected on 25 women admitted for treatment following non-penetrating TBI. Forty-five men were then matched with regards to age and injury severity. All subjects met the study criteria of having a moderate-to-severe TBI and aged 50 years old or younger. Exclusion criteria included history of previous head injury, psychiatric disturbance and significant alcohol and/or substance abuse. Data included injury details and physiological and psychometric measures of outcome. MAIN OUTCOMES AND RESULTS: Women demonstrated better outcomes as indicated by their Glasgow Outcome Scale scores (adjusted for initial injury severity and age at injury odds ratio [OR] 4.2, 95% CI 1.4-12.7) and having shorter Length of Stay (adjusted OR 9.03, 95% CI 3.13-26.08). CONCLUSIONS: Understanding the presence of sex differences in outcome following TBI is an emerging area of research. This study indicated that, after matching for initial injury severity and age at injury, women with severe TBI demonstrate a better early outcome than men.

The incidence of dysautonomia and its relationship with autonomic arousal following traumatic brain injury.

PRIMARY OBJECTIVE: To determine the incidence of autonomic arousal vs. Dysautonomia following traumatic brain injury (TBI) in an Intensive Care Unit (ICU) setting and to prospectively evaluate these groups against injury severity and outcome variables. RESEARCH DESIGN: Prospective observational group comparison (cohort) study of consecutive ICU admissions to a major trauma hospital over a 2-year period. MAIN OUTCOMES AND RESULTS: Eighty-nine of 113 subjects met inclusion and exclusion criteria, with consent gained for 79 subjects (61 male, 18 female: 89% of potential subjects). During the first 7 days post-injury, elevated autonomic parameters were almost universal in the sample (92%), predominantly hypertension and tachycardia. Nineteen of 79 subjects (24%) were autonomically aroused on day 7 (that is, had elevated heart rate, respiratory rate, blood pressure and temperature). Dysautonomia was diagnosed on day 14 post-injury in six of 79 subjects (8%) using previously published criteria. Autonomically aroused subjects had significantly more severe injuries, poorer outcomes and greater estimated costs than non-aroused subjects. Furthermore, Dysautonomic subjects within the autonomically aroused group had significantly worse outcome and, excluding early deaths, a greater period of hospitalization and higher estimated costs. CONCLUSIONS: The 8% incidence of Dysautonomia during ICU admission was in broad agreement with previous research. While day 7 autonomic arousal indicated a greater degree of injury, the diagnosis of Dysautonomia provided additional prognostic information. A coordinated multi-centre research effort into this condition appears appropriate.