Identifying medication documentation errors using handwritten versus pre‑printed ICU flowcharts

Previous studies have addressed patients in whom treatment is withheld or withdrawn after a period of intensive care unit management. However, no studies have investigated the epidemiology of patients with treatment limitations in place at the time of intensive care unit admission. To report the epidemiology and outcome of patients with treatment limitations at intensive care unit admission and to identify characteristics associated with survival and discharge to home. Retrospective database study using data from the Australian and New Zealand Intensive Care Society Adult Patient Database. Australian and New Zealand intensive care units. One hundred eighty-seven thousand four hundred and one intensive care patients collected over a 3-yr period, 5,989 (3.2%) of whom had treatment limitations at admission to the intensive care unit. Retrospective database study with no interventions. Data collected included patient characteristics, length of stay, mortality, and discharge destination. Mean intensive care unit bed days were used as a surrogate for resource consumption. Between January 1, 2007, and December 31, 2009, 5,989 (3.2%) patients were reported to the Australia and New Zealand Intensive Care Society Adult Patient Database who had treatment limitation orders at admission to intensive care unit. Mortality was 53% (95% confidence interval 51.7%-54.3%) compared with 9% (95% confidence interval 8.9%-9.1%) in patients admitted for full active management (p ≤ .001). Overall, 30% of patients with treatment limitations were discharged directly to their homes. Intensive care unit bed day usage was similar between the two groups. Within the treatment limitation group, younger patients, those with less comorbid diseases, less acute physiological disturbance, and those admitted following elective surgery, were more likely to survive and be discharged home. Admission diagnosis was an important determinant of outcome with intracranial or subarachnoid hemorrhage predicting a extremely high mortality. Patients with treatment limitations on intensive care unit admission comprise approximately 2,000 patients per year in Australia and New Zealand. Despite such limitations, almost half of these patients survive their hospital admission and a third return directly to their home.

IntroductionMobilisation of patients in the intensive care unit (ICU) is an area of growing research. Currently, there is little data on baseline mobilisation practises and the barriers to them for patients of all admission diagnoses.MethodsThe objectives of the study were to (1) quantify and benchmark baseline levels of mobilisation in Australian and Scottish ICUs, (2) compare mobilisation practises between Australian and Scottish ICUs and (3) identify barriers to mobilisation in Australian and Scottish ICUs. We conducted a prospective, observational, cohort study with a 4-week inception period. Patients were censored for follow-up upon ICU discharge or after 28 days, whichever occurred first. Patients were included if they were >18 years of age, admitted to an ICU and received mechanical ventilation in the ICU.ResultsTen tertiary ICUs in Australia and nine in Scotland participated in the study. The Australian cohort had a large proportion of patients admitted for cardiothoracic surgery (43.3 %), whereas the Scottish cohort had none. Therefore, comparison analysis was done after exclusion of patients admitted for cardiothoracic surgery. In total, 60.2 % of the 347 patients across 10 Australian ICUs and 40.1 % of the 167 patients across 9 Scottish ICUs mobilised during their ICU stay (p < 0.001). Patients in the Australian cohort were more likely to mobilise than patients in the Scottish cohort (hazard ratio 1.83, 95 % confidence interval 1.38–2.42). However, the percentage of episodes of mobilisation where patients were receiving mechanical ventilation was higher in the Scottish cohort (41.1 % vs 16.3 %, p < 0.001). Sedation was the most commonly reported barrier to mobilisation in both the Australian and Scottish cohorts. Physiological instability and the presence of an endotracheal tube were also frequently reported barriers.ConclusionsThis is the first study to benchmark baseline practise of early mobilisation internationally, and it demonstrates variation in early mobilisation practises between Australia and Scotland.

BackgroundThis paper aimed to describe the airway practices of intensive care units (ICUs) in Australia and New Zealand specific to patients presenting with COVID-19 and to inform whether consistent clinical practice was achieved. Specific clinical airway guidelines were endorsed in March 2020 by the Australian and New Zealand Intensive Care Society (ANZICS) and College of Intensive Care Medicine (CICM).Methods and findingsProspective, structured questionnaire for all ICU directors in Australia and New Zealand was completed by 69 ICU directors after email invitation from ANZICS. The online questionnaire was accessible for three weeks during September 2020 and analysed by cloud-based software. Basic ICU demographics (private or public, metropolitan or rural) and location, purchasing, airway management practices, guideline uptake, checklist and cognitive aid use and staff training relevant to airway management during the COVID-19 pandemic were the main outcome measures. The 69 ICU directors reported significant simulation-based inter-professional airway training of staff (97%), and use of video laryngoscopy (94%), intubation checklists (94%), cognitive aids (83%) and PPE “spotters” (89%) during the airway management of patients with COVID-19. Tracheal intubation was almost always performed by a Specialist (97% of ICUs), who was more likely to be an intensivist than an anaesthetist (61% vs 36%). There was a more frequent adoption of specific airway guidelines for the management of COVID-19 patients in public ICUs (94% vs 71%) and reliance on specialist intensivists to perform intubations in private ICUs (92% vs 53%).ConclusionThere was a high uptake of a standardised approach to airway management in COVID-19 patients in ICUs in Australia and New Zealand, likely due to endorsement of national guidelines.

To determine the biochemical effects of restricting the use of chloride-rich intravenous fluids in critically ill patients. Prospective, open-label, before-and-after study. University-affiliated intensive care unit. A cohort of 828 consecutive patients admitted over 6 months from February 2008 and cohort of 816 consecutive patients admitted over 6 months from February 2009. We collected biochemical and fluid use data during standard practice without clinician awareness. After a 6-month period of education and preparation, we restricted the use of chloride-rich fluids (0.9% saline [Baxter, Sydney, Australia], Gelofusine [BBraun, Melsungen, Germany], and Albumex 4 [CSL Bioplasma, Melbourne, Australia]) in the intensive care unit and made them available only on specific intensive care unit specialist prescription. Saline prescription decreased from 2411 L in the control group to 52 L in the intervention group (p < .001), Gelofusine from 538 to 0 L (p < .001), and Albumex 4 from 269 to 80 L (p < .001). As expected, Hartmann's lactated solution prescription increased from 469 to 3205 L (p < .001), Plasma-Lyte from 65 to 160 L (p < .05), and chloride-poor Albumex 20 from 87 to 268 L (p < .001). After intervention, the incidence of severe metabolic acidosis (standard base excess <-5 mEq/L) decreased from 9.1% to 6.0% (p < .001) and severe acidemia (pH <7.3) from 6.0% to 4.9% (p < .001). However, the intervention also led to significantly greater incidence of severe metabolic alkalosis (standard base excess >5 mEq/L) and alkalemia (pH >7.5) with an increase from 25.4% to 32.8% and 10.5% to 14.7%, respectively (p < .001). The time-weighted mean chloride level decreased from 104.9 ± 4.9 to 102.5 ± 4.6 mmol/L (p < .001), whereas the time-weighted mean standard base excess increased from 0.5 ± 4.5 to 1.8 ± 4.7 mmol/L (p < .001), mean bicarbonate from 25.3 ± 4.0 to 26.4 ± 4.1 mmol/L (p < .001) and mean pH from 7.40 ± 0.06 to 7.42 ± 0.06 (p < .001). Overall fluid costs decreased from $15,077 (U.S.) to $3,915. In a tertiary intensive care unit in Australia, restricting the use of chloride-rich fluids significantly affected electrolyte and acid-base status. The choice of fluids significantly modulates acid-base status in critically ill patients.

BackgroundNutrition is one of the fundamentals of care provided to critically ill adults. The volume of enteral nutrition received, however, is often much less than prescribed due to multiple functional and process issues. To deliver the prescribed volume and correct the energy deficit associated with enteral nutrition alone, parenteral nutrition can be used in combination (termed “supplemental parenteral nutrition”), but benefits of this method have not been firmly established. A multi-centre, randomised, clinical trial is currently underway to determine if prescribed energy requirements can be provided to critically ill patients by using a supplemental parenteral nutrition strategy in the critically ill.Methods/designThis prospective, multi-centre, randomised, stratified, parallel-group, controlled, phase II trial aims to determine whether a supplemental parenteral nutrition strategy will reliably and safely increase energy intake when compared to usual care. The study will be conducted for 100 critically ill adults with at least one organ system failure and evidence of insufficient enteral intake from six intensive care units in Australia and New Zealand. Enrolled patients will be allocated to either a supplemental parenteral nutrition strategy for 7 days post randomisation or to usual care with enteral nutrition. The primary outcome will be the average energy amount delivered from nutrition therapy over the first 7 days of the study period. Secondary outcomes include protein delivery for 7 days post randomisation; total energy and protein delivery, antibiotic use and organ failure rates (up to 28 days); duration of ventilation, length of intensive care unit and hospital stay. At both intensive care unit and hospital discharge strength and health-related quality of life assessments will be undertaken. Study participants will be followed up for health-related quality of life, resource utilisation and survival at 90 and 180 days post randomisation (unless death occurs first).DiscussionThis trial aims to determine if provision of a supplemental parenteral nutrition strategy to critically ill adults will increase energy intake compared to usual care in Australia and New Zealand. Trial outcomes will guide development of a subsequent larger randomised controlled trial.Trial registrationNCT01847534 (First registered 5 February 2013, last updated 14 October 2015)Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-015-1118-y) contains supplementary material, which is available to authorized users.

A questionnaire was sent to 34 hospitals in Australia, 33 in the UK and 11 in Hong Kong to investigate current physiotherapy work practices in intensive care units (ICUs). The questionnaires were returned from 32 hospitals in Australia, 21 in the UK and 9 in Hong Kong, giving a response rate of 94, 64 and 82% respectively.A 24-hour on-call physiotherapy service was available in 97% of the ICUs surveyed in the UK; however, this service was available in only 49% of the units in Australia and none of the ICUs in Hong Kong.Referral decisions were purely the verdict of the physiotherapist in 31% of the units in the UK and 27% of the units in Australia. This form of referral system, however, does not exist in Hong Kong. A physiotherapist's opinion was sought by medical staff in over 60% of the units in all three countries.The most commonly used techniques employed in all three countries were suctioning and vibration. Physiotherapists are more scientifically orientated in the UK and Australia - 28% of the units ...

BackgroundGiven the expanding scope of extracorporeal membrane oxygenation (ECMO) and its variable impact on drug pharmacokinetics as observed in neonatal studies, it is imperative that the effects of the device on the drugs commonly prescribed in the intensive care unit (ICU) are further investigated. Currently, there are no data to confirm the appropriateness of standard drug dosing in adult patients on ECMO. Ineffective drug regimens in these critically ill patients can seriously worsen patient outcomes. This study was designed to describe the pharmacokinetics of the commonly used antibiotic, analgesic and sedative drugs in adult patients receiving ECMO.Methods/DesignThis is a multi-centre, open-label, descriptive pharmacokinetic (PK) study. Eligible patients will be adults treated with ECMO for severe cardiac and/or respiratory failure at five Intensive Care Units in Australia and New Zealand. Patients will receive the study drugs as part of their routine management. Blood samples will be taken from indwelling catheters to investigate plasma concentrations of several antibiotics (ceftriaxone, meropenem, vancomycin, ciprofloxacin, gentamicin, piperacillin-tazobactum, ticarcillin-clavulunate, linezolid, fluconazole, voriconazole, caspofungin, oseltamivir), sedatives and analgesics (midazolam, morphine, fentanyl, propofol, dexmedetomidine, thiopentone). The PK of each drug will be characterised to determine the variability of PK in these patients and to develop dosing guidelines for prescription during ECMO.DiscussionThe evidence-based dosing algorithms generated from this analysis can be evaluated in later clinical studies. This knowledge is vitally important for optimising pharmacotherapy in these most severely ill patients to maximise the opportunity for therapeutic success and minimise the risk of therapeutic failure.Trial registrationACTRN12612000559819

To measure the interobserver agreement, sensitivity, specificity, positive predictive value, and negative predictive value of data submitted to a statewide surveillance system for identifying central line-associated bloodstream infection (BSI). Retrospective review of hospital medical records comparing reported data with gold standard according to definitions of central line-associated BSI. Six Victorian public hospitals with more than 100 beds. Reporting of surveillance outcomes was undertaken by infection control practitioners at the hospital sites. Retrospective evaluation of the surveillance process was carried out by independent infection control practitioners from the Victorian Hospital Acquired Infection Surveillance System (VICNISS). A sample of records of patients reported to have a central line-associated BSI were assessed to determine whether they met the definition of central line-associated BSI. A sample of records of patients with bacteremia in the intensive care unit during the assessment period who were not reported as having central line-associated BSI were also assessed to see whether they met the definition of central line-associated BSI. Records of 108 patients were reviewed; the agreement between surveillance reports and the VICNISS assessment was 67.6% (k = 0.31). Of the 46 reported central line-associated BSIs, 27 were confirmed to be central line-associated BSIs, for a positive predictive value of 59% (95% confidence interval [CI], 43%-73%). Of the 62 cases of bacteremia reviewed that were not reported as central line-associated BSIs, 45 were not associated with a central line, for a negative predictive value of 73% (95% CI, 60%-83%). Estimated sensitivity was 35%, and specificity was 87%. The positive likelihood ratio was 3.0, and the negative likelihood ratio was 0.72. The agreement between the reporting of central line-associated BSI and the gold standard application of definitions was unacceptably low. False-negative results were problematic; more than half of central line-associated BSIs may be missed in Victorian public hospitals.

The scale of the COVID‐19 pandemic represents unprecedented challenges to healthcare systems. We describe a cohort of 18 critically ill COVID‐19 patients – to our knowledge the highest number, in a single intensive care unit in Australia. We discuss the complex challenges and dynamic solutions that concern an intensive care unit pandemic response. Acting as the State's COVID‐19 referral hospital, we provide local insights to consider alongside national guidelines.

To quantify between-unit variability in mean length of stay (LoS) between intensive care units (ICUs) after adjusting for differences in case mix using a method that does not require arbitrary trimming of data. An analysis of registry data from pediatric ICUs (PICUs) in Australia and New Zealand. The relationships between patient LoS and associated patient factors were modeled as a log-linear function of the covariates using two gamma distributions. The predicted distribution is estimated as a weighted average of the two distributions where the relative weighting is conditional on the patient's elective status. Data for 12,763 admissions submitted to the Australian and New Zealand Paediatric Intensive Care Registry from the eight dedicated PICUs in Australia and New Zealand in 2007 and 2008. The two distributions of the mixture model accurately described the distribution of short- and long-stay patients in ICUs. After adjusting for patient case mix, several sites had a statistically significant effect on patient LoS. The two-compartment model characterizes ICU LoS for short- and long-stay patients more effectively than a single-compartment model. There is significant site-level variation in the LoS among children admitted to ICUs in Australia and New Zealand. Differences in the site-level variation between short- and long-stay patients indicate differences in discharge practice.

Pregnant and post-partum (collectively peri-partum) women may be at increased risk of severe COVID-19 disease. To describe the characteristics, interventions, and outcomes of peri-partum patients admitted to intensive care units (ICUs) in Australia with COVID-19. We conducted a prospective, multicentre observational study using the SPRINT-SARI Australia database across 63 ICUs in Australia. All women <45 years of age, admitted to a participating Australian ICU, with laboratory-confirmed COVID-19 between 1 March 2020 and 1 June 2023 were included. Participants were categorised as either peri-partum, defined as pregnant or up to six weeks post-partum, or non-pregnant. The primary outcome was in-hospital mortality. A total of 737 eligible female patients were admitted to ICUs over the study period: 168/737 (23%) were peri-partum, while 569/737 (77%) were non-pregnant. The median age of peri-partum women was 31 (interquartile range (IQR) 27-36) years old, and median gestation was 28.0 (IQR 4-40) weeks. When compared to non-pregnant women, peri-partum women had lower rates of comorbidities (1.8% vs 14.4% P < 0.001), lower vaccination rates (27.4% vs 45.2%, P < 0.001), similar rates of mechanical ventilation, and greater use of tocilizumab (29.2% vs 4.0%, P < 0.001). Complications were low in both groups. In-hospital mortality was lower in peri-partum patients: 1/168 (0.6%) vs 24/569 (4.2%); P = 0.04. Peri-partum patients made up ~25% of all women aged <45 years old admitted to Australian ICUs with COVID-19, and nearly 30% required mechanical ventilation. Despite lower vaccination rates in peri-partum patients, in-hospital mortality was lower than in non-pregnant patients.

Traumatic brain injury (TBI) is a major cause of death and disability, with an estimated 5.5 million people experiencing severe TBI worldwide every year. Observational clinical studies of people with TBI suggest an association between raised body temperature and unfavourable outcome, although this relationship is inconsistent. Additionally, preclinical models suggest that reducing temperature to 35 °C to 37.5 °C improves biochemical and histopathological outcomes compared to reducing temperature to a lower threshold of 33 °C to 35 °C. It is unknown whether reducing body temperature to 35 °C to 37.5 °C in people admitted to hospital with TBI is beneficial, has no effect, or causes harm. This is an update of a review last published in 2014. To assess the effects of pharmacological interventions or physical interventions given with the intention of reducing body temperature to 35 °C to 37.5 °C in adults and children admitted to hospital after TBI. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Web of Science, and PubMed on 28 November 2019. We searched clinical trials registers, grey literature and references lists of reviews, and we carried out forward citation searches of included studies. We included randomised controlled trials (RCTs) with participants of any age admitted to hospital following TBI. We included interventions that aimed to reduce body temperature to 35 °C to 37.5 °C: these included pharmacological interventions (such as paracetamol, or non-steroidal anti-inflammatory drugs), or physical interventions (such as surface cooling devices, bedside fans, or cooled intravenous fluids). Eligible comparators were placebo or usual care. Two review authors independently assessed studies for inclusion, extracted data, and assessed risks of bias. We assessed the certainty of the evidence with GRADE. We included one RCT with 41 participants. This study recruited adult participants admitted to two intensive care units in Australia, and evaluated a pharmacological intervention. Researchers gave participants 1 g paracetamol or a placebo intravenously at four-hourly intervals for 72 hours. We could not be certain whether intravenous paracetamol influenced mortality at 28 days (risk ratio 2.86, 95% confidence interval 0.32 to 25.24). We judged the evidence for this outcome to be very low certainty, meaning we have very little confidence in this effect estimate, and the true result may be substantially different to this effect. We downgraded the certainty for imprecision (because the evidence was from a single study with very few participants), and study limitations (because we noted a high risk of selective reporting bias). This study was otherwise at low risk of bias. The included study did not report the primary outcome for this review, which was the number of people with a poor outcome at the end of follow-up (defined as death or dependency, as measured on a scale such as the Glasgow Outcome Score), or any of our secondary outcomes, which included the number of people with further intracranial haemorrhage, extracranial haemorrhage, abnormal intracranial pressure, or pneumonia or other serious infections. The only other completed trial that we found was of a physical intervention that compared advanced fever control (using a surface cooling device) versus conventional fever control in 12 participants. The trial was published as an abstract only, with insufficient details to allow inclusion, so we have added this to the 'studies awaiting classification' section, pending further information from the study authors or publication of the full study report. We identified four ongoing studies that will contribute evidence to future updates of the review if they measure relevant outcomes and, in studies with a mixed population, report data separately for participants with TBI. One small study contributed very low-certainty evidence for mortality to this review. The uncertainty is largely driven by limited research into reduction of body temperature to 35 °C to 37.5 °C in people with TBI. Further research that evaluates pharmacological or physical interventions, or both, may increase certainty in this field. We propose that future updates of the review, and ongoing and future research in this field, incorporate outcomes that are important to the people receiving the interventions, including side effects of any pharmacological agent (e.g. nausea or vomiting), and discomfort caused by physical therapies.

The needs of families of trauma intensive care patients: A mixed methods study

Management of severe acute respiratory distress syndrome in Australia and New Zealand (SAGE-ANZ): An observational study

A survey of central venous catheter practices in Australian and New Zealand tertiary neonatal units