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.

Speech pathology assessment of dysphagia post endotracheal extubation: A service-model evaluation.

BACKGROUND: As postextubation dysphagia (PED) is correlated with pneumonia, feeding-tube placement, and in-hospital mortality, early identification is paramount. Endotracheal intubation duration of ≥48 h is independently predictive for PED. Therefore, a blanket intensive care unit (ICU) referral protocol was implemented to conduct PED assessment of patients intubated for ≥48 h. OBJECTIVES: The objective of this study was to review outcomes of an established blanket referral model for PED assessment in patients intubated for ≥48 h. Outcomes of the model were examined over a 2-year period (June 2015-June 2017) for (i) numbers and clinical characteristics of patients meeting criteria and referred for speech pathology (SP) assessment; (ii) frequency identified with PED on clinical swallow examination; (iii) severity and duration of PED; and (iv) SP management within the ICU. RESULTS: There was 96% adherence to the pathway with 108 participants (68% male) assessed. Median intubation duration was 142 h (mode = 61; interquartile range [IQR] = 131.75), and median ICU admission was 9 days (mode = 8; IQR = 6.75). SP referral occurred at a median of 19.5 h (mode = 4; IQR = 18.75) after extubation. Dysphagia assessment occurred at a median of 22 h (mode = 4; IQR = 19), with 34% assessed on the same day and 77% within 24 h of extubation. PED was observed in 89%, with 26% exhibiting profound PED. Dysphagia recovery occurred at a median of 7 days (mode = 2; IQR = 11). Dysphagia severity was associated with duration to swallow recovery (p = 0.001). A median of two occasions of service and 90 min clinical time was spent by the speech pathologist in the ICU. CONCLUSION: The blanket referral model enabled timely triage and assessment of dysphagia in a patient cohort at high risk of PED in our facility.

Ventilation practices in burn patients-an international prospective observational cohort study.

BACKGROUND: It is unknown whether lung-protective ventilation is applied in burn patients and whether they benefit from it. This study aimed to determine ventilation practices in burn intensive care units (ICUs) and investigate the association between lung-protective ventilation and the number of ventilator-free days and alive at day 28 (VFD-28). METHODS: This is an international prospective observational cohort study including adult burn patients requiring mechanical ventilation. Low tidal volume (V T) was defined as V T ≤ 8 mL/kg predicted body weight (PBW). Levels of positive end-expiratory pressure (PEEP) and maximum airway pressures were collected. The association between V T and VFD-28 was analyzed using a competing risk model. Ventilation settings were presented for all patients, focusing on the first day of ventilation. We also compared ventilation settings between patients with and without inhalation trauma. RESULTS: A total of 160 patients from 28 ICUs in 16 countries were included. Low V T was used in 74% of patients, median V T size was 7.3 [interquartile range (IQR) 6.2-8.3] mL/kg PBW and did not differ between patients with and without inhalation trauma (p = 0.58). Median VFD-28 was 17 (IQR 0-26), without a difference between ventilation with low or high V T (p = 0.98). All patients were ventilated with PEEP levels ≥5 cmH2O; 80% of patients had maximum airway pressures <30 cmH2O. CONCLUSION: In this international cohort study we found that lung-protective ventilation is used in the majority of burn patients, irrespective of the presence of inhalation trauma. Use of low V T was not associated with a reduction in VFD-28. TRIAL REGISTRATION: Clinicaltrials.gov NCT02312869. Date of registration: 9 December 2014.

Medication safety improvements during care transitions in an Australian intensive care unit following implementation of an electronic medication management system.

BACKGROUND: For patients requiring admission to the Intensive Care Unit (ICU), transfers of care (TOC) during admission to and discharge from the ICU are particularly high-risk periods for medication errors. In the Australian setting, commonly general wards and the ICU do not share an integrated Electronic Medical ecord (EMR) and specifically an Electronic Medication Management System (EMMS) as part of the EMR. PURPOSE: To evaluate the effect of a hospital wide integrated EMMS on medication error rates during ICU admission and at TOC. METHOD: A 6-month historical control study was performed before and after implementation of the EMMS in the ICU of a tertiary hospital. Prescribing errors detected by pharmacists in the study period were divided into phase 1, (pre-EMMS, 6months), phase 2 (3 months post implementation after shakedown stage) and phase 3 (next 3 months of post implementation). They were categorized as prescribing error types under system or clinical intervention. Chi square statistics and interrupted time series analysis were used to determine if there was significant change in the proportion of patients who had an error at TOC during each phase. Logistics regression was used to determine the relationship between the dependent (error type) and the independent variable (study phase) for errors that occurred during TOC. RESULTS: Errors occurred during TOC in 42 %, 64 % and 19 % of patients in phase 1, 2 and 3 respectively. There was a significant decline in the proportion of patients with an error between phase 1 and 3 (p < 0.01). During a patient's ICU admission, at least one medication error occurred in 28.3 %, 62.6 % and 25.1 % in phase 1, 2 and 3 respectively. Besides procedural errors, the likelihood of an error occurring was greatest in phase 1, compared to phase 2 and 3 across system-related error categories. CONCLUSION: Medication errors during TOC reduced following implementation of the integrated ICU EMMS. EMMS safety features facilitated reduced system related prescribing errors as well as the severity of errors made.

Tocilizumab for severe COVID-19 pneumonia: Case series of 5 Australian patients.

AIM: To describe the first Australian cases of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV2) disease (COVID-19) pneumonia treated with the interleukin-6 receptor antagonist tocilizumab. METHODS: Retrospective, open-label, real-world, uncontrolled, single-arm case series conducted in 2 tertiary hospitals in NSW, Australia and 1 tertiary hospital in Victoria, Australia. Five adult male patients aged between 46 and 74 years with type 1 respiratory failure due to COVID-19 pneumonia requiring intensive care unit (ICU) admission and biochemical evidence of systemic hyperinflammation (C-reactive protein greater than 100 mg/L; ferritin greater than 700 µg/L) were administered variable-dose tocilizumab. RESULTS: At between 13 and 26 days follow-up, all patients are alive and have been discharged from ICU. Two patients have been discharged home. Two patients avoided endotracheal intubation. Oxygen therapy has been ceased in three patients. Four adverse events potentially associated with tocilizumab therapy occurred in three patients: ventilator-associated pneumonia, bacteremia associated with central venous catheterization, myositis and hepatitis. All patients received broad-spectrum antibiotics, 4 received corticosteroids and 2 received both lopinavir/ritonavir and hydroxychloroquine. The time from first tocilizumab administration to improvement in ventilation, defined as a 25% reduction in fraction of inspired oxygen required to maintain peripheral oxygen saturation greater than 92%, ranged from 7 hours to 4.6 days. CONCLUSIONS: Tocilizumab use was associated with favorable clinical outcome in our patients. We recommend tocilizumab be included in randomized controlled trials of treatment for patients with severe COVID-19 pneumonia, and be considered for compassionate use in such patients pending the results of these trials.

Self-monitoring for recurrence of secondary atrial fibrillation following non-cardiac surgery or acute illness: A pilot study.

BACKGROUND: Atrial fibrillation (AF) secondary to non-cardiac surgery and medical illness is common and, although often transient, is associated with an increased risk of stroke and mortality. This pilot study tested the feasibility of self-monitoring to detect recurrent AF in this setting and the frequency with which it occurred. METHODS: Patients with new secondary AF after non-cardiac surgery or medical illness that reverted to sinus rhythm before discharge were recruited in three tertiary hospitals in Australia. Participants performed self-monitoring for AF recurrence using a Handheld single-lead ECG device 3-4 times/day for 4-weeks. RESULTS: From 16,454 admissions, 224 (1.4%) secondary AF cases were identified. Of these, 94 were eligible, and 29 agreed to participate in self-monitoring (66% male; median age 67 years). Self-monitoring was feasible and acceptable to participants in this setting. Self-monitoring identified AF recurrence in 10 participants (34%; 95% CI, 18% -54%), with recurrence occurring ≤ 9 days following discharge in 9/10 participants. Only 4 participants (40%) reported associated palpitations with recurrence. Six participants (60%) with recurrence had a CHA2DS2-VA score ≥ 2, suggesting a potential indication for oral anticoagulation. CONCLUSIONS: Approximately 1 in 3 patients with transient secondary AF will have recurrent AF within nine days of discharge. These recurrent episodes are often asymptomatic but can be detected promptly using patient self-monitoring, which was feasible and acceptable. Future research is warranted to further investigate the incidence of secondary AF, the rate of recurrence after discharge and its prognosis, and whether use of oral anticoagulation can reduce stroke in this setting.

A cross-sectional survey of Australian and New Zealand public opinion on methods totriage intensive care patients in an influenza pandemic.

BACKGROUND AND OBJECTIVE: An influenza pandemic has the potential to overwhelm intensive care resources, but the views of the general public on how resources should be allocated in such a scenario were unknown. We aimed to determine Australian and New Zealand public opinion on how intensive care unit beds should be allocated during an influenza pandemic. DESIGN, SETTING, AND PARTICIPANTS: A postal questionnaire was sent to 4000 randomly selected registered voters; 2000 people each from the Australian Electoral Commission and New Zealand Electoral Commission rolls. MAIN OUTCOME MEASURE: The respondents' preferred method to triage ICU patients in an influenza pandemic. Respondents chose from six methods: use a "first in, first served" approach; allow a senior doctor to decide; use pre-determined health department criteria; use random selection; use the patient's ability to pay; use the importance of the patient to decide. Respondents also rated each of the triage methods for fairness. RESULTS: Australian respondents preferred that patients be triaged to the ICU either by a senior doctor (43.2%) or by pre-determined health department criteria (38.7%). New Zealand respondents preferred that triage be performed by a senior doctor (45.9%). Respondents from both countries perceived triage by a senior doctor and by pre-determined health department criteria to be fair, and the other four methods of triage to be unfair. CONCLUSION: In an influenza pandemic, when ICU resources would be overwhelmed, survey respondents preferred that ICU triage be performed by a senior doctor, but also perceived the use of pre-determined triage criteria to be fair.