Research without informed patient consent in incompetent patients.

Most patients needing intensive care cannot give informed consent to participation in research. This includes the most acutely and severely ill, with the highest mortality and morbidity where research has the greatest potential to improve patient outcomes. In these circumstances consent is usually sought from a substitute decision maker, but while survivors of intensive care believe substitute decision makers will look after their interests, evidence suggests substitute decision makers are poorly equipped for this task. Various models have been suggested for research without patient informed consent when intervention is urgent and cannot wait until first person consent is possible, including a waiver of consent if conditions are met. A nationally consistent model is proposed for Australia with a robust process for initial waiver of consent followed by first person consent to further research-related procedures or ongoing follow-up when this can be competently provided.

Risk factors and outcomes of high-dependency patients requiring intensive care unit admission: a nested case-control study.

Intermediate-care or high-dependency units can provide a level of care that lies between the intensive care unit (ICU) and general ward, but the patients who are most likely to benefit from such level of care remains uncertain. This nested case-control study assessed the incidence and risk factors of high-dependency patients requiring ICU admission and whether these admissions were associated with a worse outcome when compared to other emergency ICU admissions. Seventy-seven consecutive high-dependency patients requiring ICU admission (cases) were compared with 77 patients who did not require ICU admission (controls) and also 928 emergency ICU admissions from other areas. The incidence of high-dependency patients requiring ICU admission was 6.7% (95% confidence interval 5.3 to 8.2). High-dependency admissions from the ward (odds ratio 4.46, 95% confidence interval 1.55 to 12.78) or emergency department (odds ratio 4.48, 95% confidence interval 1.54 to 13.0) and a need for concurrent non-invasive ventilation, inotrope infusion and acute kidney injury (odds ratio 14.90, 95% confidence interval 3.79 to 58.3) was associated with a higher risk of ICU admission. Hospital mortality of the high-dependency patients requiring ICU admission was not significantly different from other emergency ICU admissions (odds ratio 1.08, 95% confidence interval 0.55 to 2.11). In summary, high-dependency patients requiring ICU admission were uncommon unless they had multi-organ failure and their hospital mortality was not significantly different from other emergency ICU admissions.

Changes in case-mix and outcomes of critically ill patients in an Australian tertiary intensive care unit.

Critical care service is expensive and the demand for such service is increasing in many developed countries. This study aimed to assess the changes in characteristics of critically ill patients and their effect on long-term outcome. This cohort study utilised linked data between the intensive care unit database and state-wide morbidity and mortality databases. Logistic and Cox regression was used to examine hospital survival and five-year survival of 22,298 intensive care unit patients, respectively. There was a significant increase in age, severity of illness and Charlson Comorbidity Index of the patients over a 16-year study period. Although hospital mortality and median length of intensive care unit and hospital stay remained unchanged, one- and five-year survival had significantly improved with time, after adjusting for age, gender; severity of illness, organ failure, comorbidity, 'new' cancer and diagnostic group. Stratified analyses showed that the improvement in five-year survival was particularly strong among patients admitted after cardiac surgery (P = 0.001). In conclusion, although critical care service is increasingly being provided to patients with a higher severity of acute and chronic illnesses, long-term survival outcome has improved with time suggesting that critical care service may still be cost-effectiveness despite the changes in case-mix.

Healthcare utilisation among patients discharged from hospital after intensive care.

Surviving critical illness can be life-changing and presents new healthcare challenges for patients after hospital discharge. This feasibility study aimed to examine healthcare service utilisation for patients discharged from hospital after intensive care unit stay. Following Ethics Committee approval, patients aged 18 years and older were recruited over three months. Those admitted after cardiac surgery, discharged to another facility or against medical advice were excluded. Patients were informed of the study by post and followed-up by telephone at two and six months after discharge. General practitioners were also contacted (44% responded). Among 187 patients discharged from hospital, 11 died, 25 declined to participate and 39 could not be contacted. For 112 patients (60%) who completed a survey, the majority (82%) went home from hospital and were cared for by their partner (53%). More than half of the patients (58%) reported taking the same number of medications after intensive care unit stay but 30% took more (P = 0.023). While there was no change in the number of visits to the general practitioner for 64% of patients, 29% reported an increase after intensive care unit stay. At six months, 40% of responders who were not retired were unemployed. Discharge summary surveys revealed 39 general practitioners (71%) were satisfied with details of ongoing healthcare needs. Twenty-one general practitioners wrote comments: 10 reported insufficient information about ongoing needs/rehabilitation and two reported no mention of intensive care unit stay. Survivors of critical illness had increased healthcare needs and despite most returning home, had a low workforce participation rate. This requires further investigation to maximise the benefits of survival from critical illness.

Effect of length of stay in intensive care unit on hospital and long-term mortality of critically ill adult patients.

BACKGROUND: Critical illness leading to prolonged length of stay (LOS) in an intensive care unit (ICU) is associated with significant mortality and resource utilization. This study assessed the independent effect of ICU LOS on in-hospital and long-term mortality after hospital discharge. METHODS: Clinical and mortality data of 22 298 patients, aged 16 yr and older, admitted to ICU between 1987 and 2002 were included in this linked-data cohort study. Cox's regression with restricted cubic spline function was used to model the effect of LOS on in-hospital and long-term mortality after adjusting for age, gender, acute physiology score (APS), maximum number of organ failures, era of admission, elective admission, Charlson's co-morbidity index, and diagnosis. The variability each predictor explained was calculated by the percentage of the chi(2) statistic contribution to the total chi(2) statistic. RESULTS: Most hospital deaths occurred within the first few days of ICU admission. Increasing LOS in ICU was not associated with an increased risk of in-hospital mortality after adjusting for other covariates, but was associated with an increased risk of long-term mortality after hospital discharge. The variability on the long-term mortality effect associated with ICU LOS (2.3%) appeared to reach a plateau after the first 10 days in ICU and was not as important as age (35.8%), co-morbidities (18.6%), diagnosis (10.9%), and APS (3.6%). CONCLUSIONS: LOS in ICU was not an independent risk factor for in-hospital mortality, but it had a small effect on long-term mortality after hospital discharge after adjustment for other risk factors.

Effect of an episode of critical illness on subsequent hospitalisation: a linked data study.

Healthcare utilisation can affect quality of life and is important in assessing the cost-effectiveness of medical interventions. A clinical database was linked to two Australian state administrative databases to assess the difference in incidence of healthcare utilisation of 19,921 patients who survived their first episode of critical illness. The number of hospital admissions and days of hospitalisation per patient-year was respectively 150% and 220% greater after than before an episode of critical illness (assessed over the same time period). This was the case regardless of age or type of surgery (i.e. cardiac vs non-cardiac). After adjusting for the ageing effect of the cohort as a whole, there was still an unexplained two to four-fold increase in hospital admissions per patient-year after an episode of critical illness. We conclude that an episode of critical illness is a robust predictor of subsequent healthcare utilisation.

Promoting Global Research Excellence in Severe Sepsis (PROGRESS): lessons from an international sepsis registry.

BACKGROUND: The PROGRESS Registry (Promoting Global Research Excellence in Severe Sepsis) was designed to provide comparative data reflecting everyday clinical practice, thereby allowing participating institutions to explore and benchmark medical interventions in severe sepsis. MATERIALS AND METHODS: PROGRESS was an international, noninterventional, prospective, observational registry collecting data that describe the management and outcomes of severe sepsis patients in intensive care units (ICUs). Patients were enrolled who had been diagnosed with severe sepsis (suspected or proven infection and >or= 1 acute sepsis-induced organ dysfunction) at the participating institutions, where de-identified data were entered directly into a secured website. PROGRESS was governed by an independent international medical advisory board. RESULTS: PROGRESS took place in 276 ICUs in 37 countries, and 12,881 patients were identified as having severe sepsis. There was considerable variation among countries in enrollment levels, provision of standard treatment and supportive therapies, and ICU and hospital outcomes. Eight countries accounted for 65.2% of the enrolled patients. Males (59.3%) and Caucasian (48.6%) patients predominated the patient cohort. Diagnosis of severe sepsis was prior to ICU admission in 45.7% of patients, at ICU admission in 29.1% of patients, and after ICU admission in the remainder. Globally, ICU and hospital mortality rates were 39.2% and 49.6%, respectively. The mean length of ICU and hospital stay was 14.6 days and 28.2 days, respectively. CONCLUSIONS: The PROGRESS international sepsis registry demonstrates that a large web-based sepsis registry is feasible. Wide variations in outcomes and use of sepsis therapies were observed between countries. These results also suggest that additional opportunities exist across countries to improve severe sepsis outcomes.

Examining the occurrence of adverse events within 72 hours of discharge from the intensive care unit.

Adverse events have negative consequences for patients, including increased risk of death or permanent disability. Reports describe suboptimal patient care on hospital wards and reasons for re-admission to the intensive care unit (ICU) but limited data exists on the occurrence of adverse events, their characteristics and outcomes in patients recently discharged from the ICU to the ward. This prospective observational study describes the incidence and outcomes of adverse events within 72 hours of discharge from an Australian ICU over 12 weeks in 2006. Patients were excluded if they were admitted to ICU after booked surgery or uncomplicated drug overdose, were discharged from ICU to the high dependency unit or had a 'do-not-resuscitate' order Clinical antecedents and preventability were determined for each event. Seventeen (10%) of the 167 discharges that met the inclusion criteria were associated with an adverse event, with nine (52%) judged as probably preventable. Seven adverse events occurred from discharges between 1700 and 0700 hours and seven were on weekends. The most common adverse events were related to fluid management (47%). Outcomes included three ICU readmissions, two high dependency unit admissions and two required one-to-one ward nursing. Two adverse events resulted in temporary disability, seven resulted in prolonged hospital stays and two were associated with death. Delay in taking action for abnormal physiological signs and infrequent charting were evident. Whilst the adverse event rate compared favourably with other reports, 64% of the events were considered preventable. A review of support systems and processes is recommended to better target transition from the ICU.

The pressure effects of facemasks during noninvasive ventilation: a volunteer study.

Noninvasive ventilation by facemask is commonly used for patients with respiratory failure. We evaluated the pressure exerted by two types of facemask on the faces of 12 healthy volunteers while they were being given different levels of continuous or bi-level positive airway pressure ventilation. The mean (SD) pressure recorded on the bridge of the nose was much higher than that on the cheek (nose: 65.8 (21.2) vs cheek 15.4 (7.2) mmHg, p < 0.0001). Progressive tightening of the harness and increasing of the volume of air in the facemask cushions increased the pressure on the bridge of the nose, and the effect of these two factors was additive. Some commercially available facemasks can produce substantial pressure on the bridge of the nose and this explains why pressure complications on the bridge of the nose are common during noninvasive ventilation.

Data linkage enables evaluation of long-term survival after intensive care.

Outcomes of intensive care are important to the patient and for assessment of benefit. Short-term outcomes after critical illness are well described, but less is known about long-term outcomes. This study describes the use of data linkage, combining intensive care unit (ICU) clinical data with administrative morbidity and mortality data, to assess long-term outcomes after treatment in ICU. The hospital-based cohort study was conducted in a 22-bed general ICU in a metropolitan teaching hospital. All patient admissions admitted to ICU from 1 January 1987 to 31 December 2002 were included. The prospective ICU clinical database with patient demographics, ICU diagnoses, severity of illness, daily assessment of organ failures and common daily treatments used was linked using probabilistic methods to the state-wide hospital morbidity and mortality databases to describe long-term survival. There were 26,019 ICU admissions (22,980 patients) with 25,972 records (99.8%) linked to a hospitalization event that included the index ICU admission. Unadjusted survival was 84.7% at 1 year decreasing progressively to 50.7% at 15 years. Age, type of admission, severity of illness (measured by Acute Physiologic and Chronic Health Evaluation (APACHE) II and the presence of organ failure), ICU length of stay, comorbidity (Chronic Health Evaluation and Charlson comorbidity index) and ICU admission diagnosis, were all associated with survival at 1, 3, 5, 10, and 15 year follow-up (P<0.001 at all time points). Linkage of clinical and administrative data provides a feasible method for ascertaining long-term survival after critical illness. Age, admission severity of illness, diagnosis and comorbidity influenced long-term unadjusted survival.

An evaluation of outcome after severe trauma.

There is a perception that patients with severe trauma either die soon after the trauma or survive. This study evaluated 123 patients with severe trauma until 6 months after discharge from the Intensive Care Unit (ICU). At baseline, the median Injury Severity Score was 29 (interquartile range 20-38) and the median Acute Physiology and Chronic Health Evaluation II score was 13 (interquartile range 9-15). Injuries related to road transport accounted for 79% (97/123) of the injuries and the patients were predominantly male (66%) and young (75% < 38 years of age). The median stay in ICU was 11 days. Ten per cent of the patients (12/123) died during the study period, but one-quarter of the deaths were in hospital after discharge from ICU and one-quarter of the deaths occurred after discharge from hospital. It is impossible to carefully document the mortality due to severe trauma unless the survivors of ICU are reviewed after discharge from hospital.

The effect of different bypass flow rates and low-dose dopamine on gut mucosal perfusion and outcome in cardiac surgical patients.

The aim of this double-blind, randomized, placebo-controlled trial was to investigate the effects of different cardiopulmonary bypass flow rates and low-dose dopamine on gastric mucosal pH (pHi) and outcome. We hypothesized that by minimizing gut mucosal hypoperfusion during and after cardiac surgery endotoxin translocation may be prevented, resulting in an improved clinical outcome. Four groups of 25 patients each receiving high or low flows during bypass and low-dose dopamine or saline for 24 hours after induction of anaesthesia were studied. The pHi was measured at six time intervals over 24 hours. The combination of low-dose dopamine and a low bypass flow rate was associated with a significantly greater frequency and severity of low pHi. This group also demonstrated a significantly lower vascular resistance on admission to the intensive care unit. There may be an association between low pHi and low vascular resistance.

Critical care medicine in the Western Pacific region.

The Western Pacific region has seen rapid recent economic development but variation in the provision and organisation of intensive care units (ICUs) between different countries remains. While Japan, Australia, New Zealand, Singapore, Taiwan, Korea and Hong Kong have well developed intensive care facilities, in other countries the more limited funding for healthcare can be reflected by differential availability of modern medical technology between the public and private sectors. Other factors important to intensive care include physician training, availability of other staff and whether intensive care is delivered in "open" or "closed" units. At present only Japan, Hong Kong, the Philippines, Australia and New Zealand have a postgraduate examination in intensive care leading to recognition as an intensive care physician. In Japan, Australia, New Zealand and Indonesia each hospital usually has a single multidisciplinary (medical-surgical) ICU, whereas most other Western Pacific countries have divided medical and surgical units. In Japan, Australia, New Zealand, Hong Kong, Taiwan and Thailand, the larger ICUs are usually staffed by full-time intensivists. Future development of intensive care in the region will parallel economic development. In most countries increasing patient expectations, ageing populations and "Western" diseases will increase demand for intensive care services. Only a few countries currently have recognised programmes of training and certification in intensive care but as more adopt this process it should lead to a clearer recognition and acceptance of the role of the intensivist.

The use of antimicrobials in ten Australian and New Zealand intensive care units. The Australian and New Zealand Intensive Care Multicentre Studies Group Investigators.

A prospective standardized collection of clinical, microbiological and pharmaceutical information on antibiotic use was conducted in Australia and New Zealand intensive care units (ICUs) involving 481 consecutive critically ill patients who were receiving antibiotics for any reason while in ICU. Patients had a mean SAPS II score of 34.1 +/- 17.8 with an expected mortality of 15.6% (actual mortality 12%). Of these, 292 (60.8%) were admitted to the ICU within 72 hours of surgery. Among such surgical patients, 233 (79.9%) received antibiotics for "surgical prophylaxis" while in ICU (48% of sample population). The second largest group of patients treated with antibiotics in ICU included those with systemic inflammatory response syndrome and clinical suspicion of infection (38%). Antibiotics were prescribed for the treatment of clinically diagnosed infection in 268 patients. Clinical response was apparent in 62.6% and in most (71%) was achieved in the first 72 hours of treatment. The incidence of antimicrobial-related side-effects was 4%, mostly in the form of diarrhoea or rash (75% of all side-effects). The most commonly prescribed antimicrobials were gentamicin (n = 146), ceftriaxone (n = 98), vancomycin (n = 94) and metronidazole (n = 111). Three times daily prescription of aminoglycosides was uncommon (< 1%). Forty-one patients had a documented infection (positive culture) with a gram-negative organism. Of these, 17 received therapy with a single antibiotic and 24 received therapy with two antibiotics. Despite similar illness severity, there were six deaths in the former group and only two in the latter.

Intensive care in Australia and New Zealand. No nonsense "down under".

The year 1996 was the 21st birthday of the Australian and New Zealand Annual Scientific Meeting on Intensive Care. With this maturity many of the issues that were so troublesome to intensive care in the early years relating to identity, training, recognition, and standards have largely resolved. There are, however, no signs of complacency. We need to improve the image of a career in intensive care to trainees, expand research opportunities, and respond to the ever-changing challenges coming from administrative reorganization, budgeting constraints, and increasing public expectations. I believe the foundations have been well laid to ensure a continuing contribution by Australian and New Zealand intensivists to clinical intensive care, their hospitals, ANZICS, and a place in the global research effort in intensive care.