Publications by authors named "David Pilcher"

249 Publications

Increasing ICU capacity to accommodate higher demand during the COVID-19 pandemic.

Med J Aust 2021 Oct 12. Epub 2021 Oct 12.

Centre for Outcome and Resource Evaluation (CORE), Australian and New Zealand Intensive Care Society (ANZICS), Melbourne, VIC.

Objectives: To describe the short term capability of Australian intensive care units (ICUs) to increase capacity in response to heightened demand caused by the COVID-19 pandemic.

Design: Survey of ICU directors or delegated senior clinicians (disseminated 30 August 2021), supplemented by Australian and New Zealand Intensive Care Society (ANZICS) registry data.

Setting: All 194 public and private Australian ICUs.

Main Outcome Measures: Numbers of currently available and potentially available ICU beds in case of a surge; available levels of ICU-relevant equipment and staff.

Results: All 194 ICUs Australian responded to the survey. The total number of currently open staffed ICU beds was 2183, 195 fewer (8.2%) than in 2020; the decline was greater for rural/regional (18%) and private ICUs (18%). The reported maximal ICU bed capacity (5623) included 813 additional physical ICU bed spaces and 2627 "surge areas" outside ICUs. The number of available ventilators (7196) exceeded the maximum number of ICU beds. However, the reported available number of additional nursing staff would facilitate the immediate opening of 383 additional physical ICU beds (47%), but not the additional bed spaces outside ICUs.

Conclusions: The number of currently available staffed ICU beds was lower than in 2020. Equipment shortfalls have been remediated, with sufficient ventilators to equip every ICU bed. ICU capacity can be increased in response to demand, but is constrained by the availability of appropriately trained staff. Fewer than half the potentially additional physical ICU beds could be opened with currently available staff levels while maintaining pre-pandemic models of care.
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http://dx.doi.org/10.5694/mja2.51318DOI Listing
October 2021

Association Between Urine Output and Mortality in Critically Ill Patients: A Machine Learning Approach.

Crit Care Med 2021 Sep 22. Epub 2021 Sep 22.

School of Medicine, Griffith University, Southport, QLD, Australia. Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia. Centre for Transformative Innovation, Faculty of Business and Law, Swinburne University of Technology, Hawthorn, VIC, Australia. Department of Data Science and AI, Faculty of Information Technology, Monash University, Melbourne, VIC, Australia. School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia. Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia. Department of Cardiology, Alfred Hospital, Melbourne, VIC, Australia. Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia. Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.

Objectives: Current definitions of acute kidney injury use a urine output threshold of less than 0.5 mL/kg/hr, which have not been validated in the modern era. We aimed to determine the prognostic importance of urine output within the first 24 hours of admission to the ICU and to evaluate for variance between different admission diagnoses.

Design: Retrospective cohort study.

Setting: One-hundred eighty-three ICUs throughout Australia and New Zealand from 2006 to 2016.

Patients: Patients greater than or equal to 16 years old who were admitted with curative intent who did not regularly receive dialysis. ICU readmissions during the same hospital admission and patients transferred from an external ICU were excluded.

Measurements And Main Results: One hundred and sixty-one thousand nine hundred forty patients were included with a mean urine output of 1.05 mL/kg/hr and an overall in-hospital mortality of 7.8%. A urine output less than 0.47 mL/kg/hr was associated with increased unadjusted in-hospital mortality, which varied with admission diagnosis. A machine learning model (extreme gradient boosting) was trained to predict in-hospital mortality and examine interactions between urine output and survival. Low urine output was most strongly associated with mortality in postoperative cardiovascular patients, nonoperative gastrointestinal admissions, nonoperative renal/genitourinary admissions, and patients with sepsis.

Conclusions: Consistent with current definitions of acute kidney injury, a urine output threshold of less than 0.5 mL/kg/hr is modestly predictive of mortality in patients admitted to the ICU. The relative importance of urine output for predicting survival varies with admission diagnosis.
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http://dx.doi.org/10.1097/CCM.0000000000005310DOI Listing
September 2021

Pulmonary alveolar proteinosis with an unusual bronchoscopic complication.

Respirol Case Rep 2021 Nov 4;9(11):e0856. Epub 2021 Oct 4.

Department of Respiratory and Sleep Medicine Austin Health Heidelberg Victoria Australia.

Pulmonary alveolar proteinosis (PAP) is a rare respiratory syndrome, which can be challenging to diagnose given its non-specific presentation and imaging findings. While most primary cases of PAP have an autoimmune basis, the triggers for the disease are uncertain with occupational factors increasingly thought to be important. We report the unusual complication of pneumomediastinum and bilateral pneumothoraces following endobronchial ultrasound-guided transbronchial needle aspirate in the setting of PAP. We discuss the possible physiological mechanisms of this complication, which appears to be more common in conditions with reduced lung compliance.
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http://dx.doi.org/10.1002/rcr2.856DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8488443PMC
November 2021

Rehabilitation outcomes of survivors of cardiac arrest admitted to ICUs in Australia and New Zealand (ROSC ANZ): A data linkage study.

Resuscitation 2021 Sep 15. Epub 2021 Sep 15.

Department of Epidemiology and Preventive Medicine, Monash University, Melbourne 3004, Australia; Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Australia.

Introduction: Rehabilitation outcomes in cardiac arrest survivors are largely unknown, with no data comparing out-of-hospital cardiac arrests (OHCA) and in-hospital cardiac arrests (IHCA). This study aimed to describe and compare inpatient rehabilitation outcomes in these patients who were admitted from intensive care units (ICU).

Methods: A retrospective linkage and analysis of cardiac arrest patients in the Australian and New Zealand Intensive Care Society Adult Patient Database and the Australasian Rehabilitation Outcomes Centre inpatient dataset discharged to inpatient rehabilitation between January 2017 and June 2018. Primary outcome was the functional improvement during rehabilitation (difference between the Functional Independence Measurement (FIM) score on admission and discharge). Multivariate regression analyses were performed to determine factors associated with functional improvement.

Results: In the 240 (84 OHCA and 156 IHCA) patients included, the median length of inpatient rehabilitation was 15 days [1st-3rd quartile (Q1-Q3): 9-24]. OHCA patients were more likely to be admitted to rehabilitation for neurological issues (41.7%) and IHCA for medical reasons (51.9%). Median (Q1-Q3) change in total FIM scores was similar between the two groups (24.5[10-37]) vs 21[11-31], adjusted p = 0.20), with most of the FIM change seen in the motor items, and this was only associated with a lower admission FIM score. The majority of OHCA and IHCA patients were discharged home (91.5% and 89.7%, respectively), although with an increased need for a carer at home compared to baseline (27.2% to 55.6%).

Conclusion: Patients discharged from ICU following OHCA and IHCA achieved reasonable and similar functional improvement during inpatient rehabilitation.
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http://dx.doi.org/10.1016/j.resuscitation.2021.09.008DOI Listing
September 2021

Predicting atrial fibrillation after cardiac surgery: a scoping review of associated factors and systematic review of existing prediction models.

Perfusion 2021 Aug 18:2676591211037025. Epub 2021 Aug 18.

Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, VIC, Australia.

Introduction: Postoperative atrial fibrillation (POAF) is common after cardiac surgery and associated with increased hospital length of stay, patient morbidity and mortality. We aimed to identify factors associated with POAF and evaluate the accuracy of available POAF prediction models.

Methods: We screened articles from Ovid MEDLINE and PubMed Central (PMC) and included studies that evaluated risk factors associated with POAF or studies that designed or validated POAF prediction models. We only included studies in cardiac surgical patients with sample size ⩾ 50 and a POAF outcome group ⩾20. We summarised factors that were associated with POAF and assessed prediction model performance by reviewing reported calibration and discriminative ability.

Results: We reviewed 232 studies. Of these, 142 fulfilled the inclusion criteria. Age was frequently found to be associated with POAF, while most other variables showed contradictory findings, or were assessed in few studies. Overall, 15 studies specifically developed and/or validated 12 prediction models. Of these, all showed poor discrimination or absent calibration in predicting POAF in externally validated cohorts.

Conclusions: Except for age, reporting of factors associated with POAF is inconsistent and often contradictory. Prediction models have low discrimination, missing calibration statistics, are at risk of bias and show limited clinical applicability. This suggests the need for studies that prospectively collect AF relevant data in large cohorts and then proceed to validate findings in external data sets.
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http://dx.doi.org/10.1177/02676591211037025DOI Listing
August 2021

An Exploratory Analysis of the Association between Hypercapnia and Hospital Mortality in Critically Ill Patients with Sepsis.

Ann Am Thorac Soc 2021 Aug 11. Epub 2021 Aug 11.

Austin Hospital, 96043, Heidelberg, Victoria, Australia.

Rationale: Hypercapnia may affect the outcome of sepsis. Very few clinical studies conducted in non-critically ill patients, have investigated the effects of hypercapnia and hypercapnic acidemia in the context of sepsis. The effect of hypercapnia in critically ill patients with sepsis remains inadequately studied.

Objective: To investigate the association of hypercapnia with hospital mortality in septic critically ill patients.

Methods: This is a retrospective study conducted in three tertiary public hospitals. Septic critically ill patients from three intensive care units between January 2011 and May 2019 were included. Five cohorts (exposure of at least 24, 48, 72, 120 and 168 hours) were created to account for immortal time bias and informative censoring. The association between hypercapnia exposure and hospital mortality was assessed with multivariable models. Subgroup analyses compared ventilated vs. non-ventilated and pulmonary vs. non-pulmonary sepsis patients.

Results: We analyzed 84,819 PaCO2 measurements in 3,153 patients (57.6% male; median age was 62.5 years). After adjustment for key confounders, both in mechanically ventilated and non-ventilated patients and in patients with pulmonary sepsis, there was no independent association of hypercapnia with hospital mortality. In contrast, in ventilated patients, the presence of prolonged exposure to both hypercapnia and acidemia was associated with increased mortality (highest Odds Ratio of 16.5 for at least 120 hours of potential exposure; P = 0.007).

Conclusion: After adjustment, isolated hypercapnia was not associated with increased mortality in septic patients. These hypothesis-generating observations suggest that as hypercapnia is not an independent risk factor for mortality, trials of permissive hypercapnia in sepsis may be safe.
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http://dx.doi.org/10.1513/AnnalsATS.202102-104OCDOI Listing
August 2021

Family visitation policies, facilities, and support in Australia and New Zealand intensive care units: A multicentre, registry-linked survey.

Aust Crit Care 2021 Aug 2. Epub 2021 Aug 2.

ANZICS Centre for Outcome and Resource Evaluation, Camberwell, Victoria, Australia; Intensive Care Unit, St John of God Hospital, Perth, Western Australia, Australia; School of Medicine, University of Western Australia, Perth, Western Australia, Australia. Electronic address:

Objective: The objective of this study was to describe family visitation policies, facilities, and support in Australia and New Zealand (ANZ) intensive care units (ICUs).

Methods: A survey was distributed to all Australian and New Zealand ICUs reporting to the Australian and New Zealand Intensive Care Society Centre for Outcomes and Resources Evaluation Critical Care Resources (CCR) Registry in 2018. Data were obtained from the survey and from data reported to the CCR Registry. For this study, open visiting (OV) was defined as allowing visitors for more than 14 h per day.

Setting And Participants: This study included all Australian and New Zealand ICUs reporting to CCR in 2018.

Main Outcome Measures: The main outcome measures were family access to the ICU and visiting hours, characteristics of the ICU waiting area, and information provided to and collected from the relatives.

Findings: Fifty-six percent (95/170) of ICUs contributing to CCR responded, representing 44% of ANZ ICUs and a range of rural, metropolitan, tertiary, and private ICUs. Visiting hours ranged from 1.5 to 24 h per day, with 68 (72%) respondent ICUs reporting an OV policy, of which 64 (67%) ICUs were open to visitors 24 h a day. A waiting room was part of the ICU for 77 (81%) respondent ICUs, 74 (78%) reported a separate dedicated room for family meetings, and 83 (87%) reported available social worker services. Most ICUs reported facilities for sleeping within or near the hospital. An information booklet was provided by 64 (67%) ICUs. Only six (6%) ICUs required personal protective equipment for all visitors, and 76 (80%) required personal protective equipment for patients with airborne precautions.

Conclusions: In 2018, the majority of ANZ ICUs reported liberal visiting policies, with substantial facilities and family support.
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http://dx.doi.org/10.1016/j.aucc.2021.06.009DOI Listing
August 2021

Intensive care unit strain and mortality risk in patients admitted from the ward in Australia and New Zealand.

J Crit Care 2021 Aug 2. Epub 2021 Aug 2.

Department of Intensive Care, The Alfred Hospital, Commercial Road, Prahran, Melbourne, Victoria 3004, Australia; The Australian and New Zealand Intensive Care-Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3004, Australia; The Australian and New Zealand Intensive Care Society (ANZICS), Centre for Outcome and Resource Evaluation (CORE), 277 Camberwell Road, Camberwell, Victoria 3124, Australia.

Purpose: ICU strain (low number of available beds) may be associated with a delay and altered threshold for ICU admission and adverse patient outcomes. We aimed to investigate the impact of ICU strain on hospital mortality in critically ill patients admitted from wards across Australia and New Zealand.

Materials And Methods: Ward patient admitted to ICU and ICU bed data at 137 hospitals were accessed between January 2013 and December 2016. ICU strain was classified as low (≤0.5 patients admitted per available ICU bed in a 6-h block), medium (0.5 to ≤1) or high (>1). Logistic regression models were used to examine the relationship between ICU strain and hospital mortality.

Results: 57,844 ICU admissions were analysed, with the majority (64.4%) admitted to medium-strain ICUs. Those admitted to high-strain ICUs spent longer in hospital prior to ICU than medium-strain or low-strain ICUs. After adjusting for confounders those admitted to high-strain ICUs [OR 1.24 (95%CI 1.14-1.35)] or medium-strain ICUs [OR 1.18 (95%CI 1.09-1.27)], (p < 0.001) had a higher risk of death compared low-strain ICUs.

Conclusion: ICU strain is associated with longer times in hospital prior to ICU admission and was associated with increased risk of death in patients admitted from ward.
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http://dx.doi.org/10.1016/j.jcrc.2021.07.018DOI Listing
August 2021

Perceptions held by healthcare professionals concerning organ donation after circulatory death in an Australian intensive care unit without a local thoracic transplant service: A descriptive exploratory study.

Aust Crit Care 2021 Jul 29. Epub 2021 Jul 29.

Department of Intensive Care, The Alfred Hospital, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; DonateLife Victoria, DonateLife, Melbourne.

Background And Objective: Organ donation rates continue to be low in Australia compared with demand. Donation after circulatory death (DCD) has been an important strategy to increase donation rates, facilitated by advances in cardiopulmonary support in intensive care units (ICUs). However, DCD may harbour greater logistical challenges and unfavourable perceptions amongst some ICU healthcare professionals. The aim of this study was to evaluate and understand DCD perceptions at an Australian tertiary hospital.

Methods: This descriptive exploratory study was conducted at an Australian tertiary hospital. Participants were recruited voluntarily for interview via email and word-of-mouth through the hospital's ICU network. The study used a mixed-methods approach; five close-ended questions were included in the form of Likert scales followed by a semistructured interview with open-ended questions designed to understand participants' perceptions of DCD. Interviews were recorded, transcribed, and thematically analysed.

Results: Sixteen participants were interviewed including eight intensive care doctors, four donation specialist nursing coordinators (DSNCs), and four bedside nurses. Likert responses demonstrated clinicians' support for both DCD and donation after brain death (DBD). Thematic analysis of the transcripts yielded three overarching themes including 'Contextual and environmental influences on DCD decision-making', 'Personal difficulties faced by clinicians in DCD decision-making', and 'Family influences on DCD decision-making'. Significant geographical separation between donation and organ retrieval teams, incurring significant resource utilisation, impacted the donation team's decision-making around DCD, as did a perceived disruption of ICU care to facilitate donation especially for cases where successful DCD was identified to be unlikely.

Conclusions: Overall, DCD was as acceptable to participants as DBD. However, the geographical separation of this centre meant that logistical barriers potentially impacted the DCD process. Open lines of communication with transplant centres, local resourcing, and a culture of education, experience, and leadership may facilitate the DCD programs where distant retrieval is commonplace.
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http://dx.doi.org/10.1016/j.aucc.2021.06.013DOI Listing
July 2021

The impact of distance on post-ICU disability.

Aust Crit Care 2021 Jul 25. Epub 2021 Jul 25.

Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; Monash Partners Academic Health Science Centre, Australia. Electronic address:

Background: Nonurban residential living is associated with adverse outcomes for a number of chronic health conditions. However, it is unclear what effect it has amongst survivors of critical illness.

Objectives: The purpose of this study is to determine whether patients living greater than 50 km from the treating intensive care unit (ICU) have disability outcomes at 6 months that differ from people living within 50 km.

Methods: This was a multicentre, prospective cohort study conducted in five metropolitan ICUs. Participants were adults admitted to the ICU, who received >24 h of mechanical ventilation and survived to hospital discharge. In a secondary analysis of these data, the cohort was dichotomised based on residential distance from the treating ICU: <50 km and ≥50 km. The primary outcome was patient-reported disability using the 12-item World Health Organization's Disability Assessment Schedule (WHODAS 2.0). This was recorded at 6 months after ICU admission by telephone interview. Secondary outcomes included health status as measured by EQ-5D-5L return to work and psychological function as measured by the Hospital Anxiety and Depression Scale (HADS). Multivariable logistic regression was used to assess the association between distance from the ICU and moderate to severe disability, adjusted for potential confounders. Variables included in the multivariable model were deemed to be clinically relevant and had baseline imbalance between groups (p < 0.10). These included marital status and hours of mechanical ventilation. Sensitivity analysis was also conducted using distance in kilometres as a continuous variable.

Results: A total of 262 patients were enrolled, and 169 (65%) lived within 50 km of the treating ICU and 93 (35%) lived ≥50 km from the treating ICU (interquartile range [IQR] 10-664 km). There was no difference in patient-reported disability at 6 months between patients living <50 km and those living ≥50 km (WHODAS total disability % [IQR] 10.4 [2.08-25] v 14.6 [2.08-20.8], P = 0.74). There was also no difference between groups for the six major life domains of the WHODAS. There was no difference in rates of anxiety or depression as measured by HADS score (HADS anxiety median [IQR] 4 [1-7] v 3 [1-7], P = 0.60) (HADS depression median [IQR] 3 [1-6] v 3 [1-6], P = 0.62); health status as measured by EQ-5D (mean [SD] 66.7 [20] v 69.8 [22.2], P = 0.24); or health-related unemployment (% (N) 39 [26] v 25 [29.1], P = 0.61). After adjusting for confounders, living ≥50 km from the treating ICU was not associated with increased disability (odds ratio 0.61, 95% confidence interval: 0.33-1.16; P = 0.13) CONCLUSIONS: Survivors of intensive care in Victoria, Australia, who live at least 50 km from the treating ICU did not have greater disability than people living less than 50 km at 6 months after discharge. Living 50 km or more from the treating ICU was not associated with disability, nor was it associated with anxiety or depression, health status, or unemployment due to health.
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http://dx.doi.org/10.1016/j.aucc.2021.05.013DOI Listing
July 2021

Genomic surveillance of antimicrobial resistant bacterial colonisation and infection in intensive care patients.

BMC Infect Dis 2021 Jul 14;21(1):683. Epub 2021 Jul 14.

Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia.

Background: Third-generation cephalosporin-resistant Gram-negatives (3GCR-GN) and vancomycin-resistant enterococci (VRE) are common causes of multi-drug resistant healthcare-associated infections, for which gut colonisation is considered a prerequisite. However, there remains a key knowledge gap about colonisation and infection dynamics in high-risk settings such as the intensive care unit (ICU), thus hampering infection prevention efforts.

Methods: We performed a three-month prospective genomic survey of infecting and gut-colonising 3GCR-GN and VRE among patients admitted to an Australian ICU. Bacteria were isolated from rectal swabs (n = 287 and n = 103 patients ≤2 and > 2 days from admission, respectively) and diagnostic clinical specimens between Dec 2013 and March 2014. Isolates were subjected to Illumina whole-genome sequencing (n = 127 3GCR-GN, n = 41 VRE). Multi-locus sequence types (STs) and antimicrobial resistance determinants were identified from de novo assemblies. Twenty-three isolates were selected for sequencing on the Oxford Nanopore MinION device to generate completed reference genomes (one for each ST isolated from ≥2 patients). Single nucleotide variants (SNVs) were identified by read mapping and variant calling against these references.

Results: Among 287 patients screened on admission, 17.4 and 8.4% were colonised by 3GCR-GN and VRE, respectively. Escherichia coli was the most common species (n = 36 episodes, 58.1%) and the most common cause of 3GCR-GN infection. Only two VRE infections were identified. The rate of infection among patients colonised with E. coli was low, but higher than those who were not colonised on admission (n = 2/33, 6% vs n = 4/254, 2%, respectively, p = 0.3). While few patients were colonised with 3GCR- Klebsiella pneumoniae or Pseudomonas aeruginosa on admission (n = 4), all such patients developed infections with the colonising strain. Genomic analyses revealed 10 putative nosocomial transmission clusters (≤20 SNVs for 3GCR-GN, ≤3 SNVs for VRE): four VRE, six 3GCR-GN, with epidemiologically linked clusters accounting for 21 and 6% of episodes, respectively (OR 4.3, p = 0.02).

Conclusions: 3GCR-E. coli and VRE were the most common gut colonisers. E. coli was the most common cause of 3GCR-GN infection, but other 3GCR-GN species showed greater risk for infection in colonised patients. Larger studies are warranted to elucidate the relative risks of different colonisers and guide the use of screening in ICU infection control.
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http://dx.doi.org/10.1186/s12879-021-06386-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8278603PMC
July 2021

Associations Between Socioeconomic Status, Patient Risk, and Short-Term Intensive Care Outcomes.

Crit Care Med 2021 09;49(9):e849-e859

School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.

Objectives: To investigate the association of socioeconomic status as measured by the average socioeconomic status of the area where a person resides on short-term mortality in adults admitted to an ICU in Queensland, Australia.

Design: Secondary data analysis using de-identified data from the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation linked to the publicly available area-level Index of Relative Socioeconomic Advantage and Disadvantage from the Australian Bureau of Statistics.

Setting: Adult ICUs from 35 hospitals in Queensland, Australia, from 2006 to 2015.

Patients: A total of 218,462 patient admissions.

Interventions: None.

Measurements And Main Results: The outcome measure was inhospital mortality. The main study variable was decile of Index of Relative Socioeconomic Advantage and Disadvantage. The overall crude inhospital mortality was 7.8%; 9% in the most disadvantaged decile and 6.9% in the most advantaged decile (p < 0.001). Increasing socioeconomic disadvantage was associated with increasing severity of illness as measured by Acute Physiology and Chronic Health Evaluation III score, admission with a diagnosis of sepsis or trauma, cardiac, respiratory, renal, and hepatic comorbidities, and remote location. Increasing socioeconomic advantage was associated with elective surgical admission, hematological and oncology comorbidities, and admission to a private hospital (all p < 0.001). After excluding patients admitted after elective surgery, in the remaining 106,843 patients, the inhospital mortality was 13.6%, 13.3% in the most disadvantaged, and 14.1% in the most advantaged. There was no trend in mortality across deciles of socioeconomic status after excluding elective surgery patients. In the logistic regression model adjusting for severity of illness and diagnosis, there was no statistically significant difference in the odds ratio of inhospital mortality for the most disadvantaged decile compared with other deciles. This suggests variables used for risk adjustment may lie on the causal pathway between socioeconomic status and outcome in ICU patients.

Conclusions: Socioeconomic status as defined as Index of Relative Socioeconomic Advantage and Disadvantage of the area in which a patient lives was associated with ICU admission diagnosis, comorbidities, severity of illness, and crude inhospital mortality in this study. Socioeconomic status was not associated with inhospital mortality after excluding elective surgical patients or when adjusted for severity of illness and admission diagnosis. Commonly used measures for risk adjustment in intensive care improve understanding of the pathway between socioeconomic status and outcomes.
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http://dx.doi.org/10.1097/CCM.0000000000005051DOI Listing
September 2021

The Relationship between Frailty and Mechanical Ventilation: A Population-based Cohort Study.

Ann Am Thorac Soc 2021 Jul 2. Epub 2021 Jul 2.

Monash University, 2541, Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Melbourne, Victoria, Australia.

Rationale: Frailty in critically ill patients is associated with higher mortality and prolonged length of stay, however little is known about the impact on the duration of mechanical ventilation.

Objectives: To identify the relationship between frailty and total duration of mechanical ventilation and the interaction with patients' age.

Methods: This retrospective population-based cohort study was performed using data submitted to the Australian and New Zealand Intensive Care Society Adult Patient Database between 2017 and 2020. We analyzed adult critically ill patients who received invasive mechanical ventilation within the first 24 hours of intensive care unit admission.

Results: Of 59319 available patients receiving invasive mechanical ventilation, 8331 (14%) were classified as frail. Patients with frailty had longer duration of mechanical ventilation compared to patients without frailty. Duration of mechanical ventilation increased with higher frailty score. Patients with frailty had longer intensive care unit and hospital stay with higher mortality than non-frail patients. After adjustment for relevant covariates in multivariate analyses, frailty was significantly associated with a reduced probability of cessation of invasive mechanical ventilation (adjusted hazard ratio 0.57 [95% CI: 0.51-0.64]; p<0.001). Sensitivity and subgroup analyses suggested that frailty could prolong mechanical ventilation in survivors and the relationship was especially strong in younger patients.

Conclusions: Frailty score was independently associated with longer duration of mechanical ventilation and contributed to identify patients who were less likely to be liberated from mechanical ventilation. The impact of frailty on ventilation time varied with age and was most apparent for younger patients.
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http://dx.doi.org/10.1513/AnnalsATS.202102-178OCDOI Listing
July 2021

An Audit of Lung Donor Pool: Optimal Current Donation Strategies and the Potential of Novel Time-Extended Donation After Circulatory Death Donation.

Heart Lung Circ 2021 Jun 25. Epub 2021 Jun 25.

Lung Transplant Service, The Alfred Hospital and Monash University, Melbourne, Vic, Australia.

Background: In Australia, increased organ donation and subsequent lung transplantation (LTx) rates have followed enhanced donor identification, referral and management, as well as the introduction of a donation after circulatory death (DCD) pathway. However, the number of patients waiting for LTx still continues to exceed the number of lung donors and the search for further suitable donors is critical.

Methods: All 2014-2018 Victorian DonateLife hospital deaths after intensive care unit (ICU) admission were analysed retrospectively to quantify unrecognised lung donors using current criteria, as well as novel time-extended (90 mins-24 hrs post-withdrawal) DCD lung donors.

Results: Using standard lung donor eligibility criteria, we identified 473 potential lung donors and a further 122 time-extended DCD potential lung donors among 3,538 patients meeting general eligibility criteria. Detailed review of end-of-life discussions with patient families and the reasons why they were not offered donation revealed several categories of additional lung donors-traditional lung donors missed in current practice (n=2); hepatitis C infected lung donors potentially treatable with direct-acting antivirals (n=14), time-extended DCD lung donors (n=60); donor lungs potentially suitable for transplant with use of ex-vivo lung perfusion (EVLP) (n=7).

Conclusion: While the number of lung donor opportunities missed under existing DonateLife donor identification and management processes was limited, a time-extended DCD lung donation pathway could substantially expand the lung donor pool. The use of hepatitis C infected donors, and the possibility of EVLP to solve donor graft assessment or logistic issues, could also provide small additional lung donor opportunities.
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http://dx.doi.org/10.1016/j.hlc.2021.05.094DOI Listing
June 2021

Management of hypercapnia in critically ill mechanically ventilated patients-A narrative review of literature.

J Intensive Care Soc 2020 Nov 30;21(4):327-333. Epub 2020 Mar 30.

ANZIC-RC, Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.

The use of lower tidal volume ventilation was shown to improve survival in mechanically ventilated patients with acute lung injury. In some patients this strategy may cause hypercapnic acidosis. A significant body of recent clinical data suggest that hypercapnic acidosis is associated with adverse clinical outcomes including increased hospital mortality. We aimed to review the available treatment options that may be used to manage acute hypercapnic acidosis that may be seen with low tidal volume ventilation. The databases of MEDLINE and EMBASE were searched. Studies including animals or tissues were excluded. We also searched bibliographic references of relevant studies, irrespective of study design with the intention of finding relevant studies to be included in this review. The possible options to treat hypercapnia included optimising the use of low tidal volume mechanical ventilation to enhance carbon dioxide elimination. These include techniques to reduce dead space ventilation, and physiological dead space, use of buffers, airway pressure release ventilation and prone positon ventilation. In patients where hypercapnic acidosis could not be managed with lung protective mechanical ventilation, extracorporeal techniques may be used. Newer, minimally invasive low volume venovenous extracorporeal devices are currently being investigated for managing hypercapnia associated with low and ultra-low volume mechanical ventilation.
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http://dx.doi.org/10.1177/1751143720915666DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8142102PMC
November 2020

Routine Frailty Screening in Critical Illness: A Population-Based Cohort Study in Australia and New Zealand.

Chest 2021 Oct 4;160(4):1292-1303. Epub 2021 Jun 4.

Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia; Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia.

Background: Frailty is associated with poor outcomes in critical illness. However, it is unclear whether frailty screening on admission to the ICU can be conducted routinely at the population level and whether it has prognostic importance.

Research Question: Can population-scale frailty screening with the Clinical Frailty Scale (CFS) be implemented for critically ill adults in Australia and New Zealand (ANZ) and can it identify patients at risk of negative outcomes?

Study Design And Methods: We conducted a binational prospective cohort study of critically ill adult patients admitted between July 1, 2018, and June 30, 2020, in 175 ICUs in ANZ. We classified frailty with the CFS on admission to the ICU. The primary outcome was in-hospital mortality; secondary outcomes were length of stay (LOS), discharge destination, complications (delirium, pressure injury), and duration of survival.

Results: We included 234,568 critically ill patients; 45,245 (19%) were diagnosed as living with frailty before ICU admission. Patients with vs without frailty had higher in-hospital mortality (16% vs 5%; P < .001), delirium (10% vs 4%; P < .001), longer LOS in the ICU and hospital, and increased new chronic care discharge (3% vs 1%; P < .001), with worse outcomes associated with increasing CFS category. Of patients with very severe frailty (CFS score, 8), 39% died in hospital vs 2% of very fit patients (CFS score, 1; multivariate categorical CFS score, 8 [reference, 1]; OR, 7.83 [95% CI, 6.39-9.59]; P < .001). After adjustment for illness severity, frailty remained highly significantly predictive of mortality, including among patients younger than 50 years, with improvement in the area under the receiver operating characteristic curve of the Acute Physiology and Chronic Health Evaluation III-j score to 0.882 (95% CI, 0.879-0.885) from 0.868 (95% CI, 0.866-0.871) with the addition of frailty (P < .001).

Interpretation: Large-scale population screening for frailty degree in critical illness was possible and prognostically important, with greater frailty (especially CFS score of ≥ 6) associated with worse outcomes, including among younger patients.
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http://dx.doi.org/10.1016/j.chest.2021.05.049DOI Listing
October 2021

Preparation for airway management in Australia and New Zealand ICUs during the COVID -19 pandemic.

PLoS One 2021 7;16(5):e0251523. Epub 2021 May 7.

Intensive Care Unit, Royal North Shore, Sydney, NSW, Australia.

Background: This 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 Findings: Prospective, 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%).

Conclusion: There 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.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0251523PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8104394PMC
May 2021

Hazardous and harmful alcohol use in the Northern Territory, Australia: the impact of alcohol policy on critical care admissions using an extended sampling period.

Addiction 2021 10 23;116(10):2653-2662. Epub 2021 Apr 23.

Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.

Aims: To describe the effect of alcohol policy on the incidence of intensive care unit (ICU) admissions associated with hazardous and harmful alcohol use in the Northern Territory (NT) of Australia DESIGN, SETTING AND PARTICIPANTS: Before and after analysis of admissions to NT ICUs between April 2018 and September 2019, extending on both a descriptive study describing hazardous and harmful alcohol use and single-centre analyses of harm minimization policies. After exclusions, 2281 (83%) admissions were analysed, 20.3% of which were associated with hazardous and harmful alcohol use.

Measurements: Primary outcome was the incidence of admissions associated with hazardous and harmful alcohol use in the 5 months preceding (baseline period) the introduction of new alcohol policies [full-time stationing of Police Auxiliary Liquor Inspectors (PALIs) and minimum unit price (MUP)] compared with 12 months (post-intervention) following. Secondary outcomes included measures of resource use [length of stay (LoS), need for mechanical ventilation] and mortality, stratified by site.

Findings: Overall, there was a 4.5% [95% confidence interval (CI) = 0.8-8.2%] absolute risk reduction between the time-periods (95% CI = 23.4 versus 18.9% for baseline and post-intervention, respectively, P = 0.01), predominantly due to a reduction in admissions associated with acute misuse (2.3%, 95% CI = -0.2 to 4.9% risk reduction, P = 0.06). There were regional differences, with a more marked relative risk reduction observed in Central Australia compared with the city of Darwin (27.0 versus 16.7% relative risk reduction, respectively).

Conclusions: Introduction of new alcohol harm minimization policies in the Northern Territory of Australia appears to have reduced the number of intensive care unit admissions associated with hazardous and harmful alcohol use. Strength of effect varies by geographical region and chronicity of hazardous and harmful alcohol use.
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http://dx.doi.org/10.1111/add.15432DOI Listing
October 2021

Does equipoise exist amongst experts regarding the role of hyperbaric oxygen treatment for necrotising soft tissue infection?

ANZ J Surg 2021 04;91(4):485-487

Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1111/ans.16337DOI Listing
April 2021

Infection management processes in intensive care and their association with mortality.

J Antimicrob Chemother 2021 06;76(7):1920-1927

Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia.

Background: ICU-specific tables of antimicrobial susceptibility for key microbial species ('antibiograms'), antimicrobial stewardship (AMS) programmes and routine rounds by infectious diseases (ID) physicians are processes aimed at improving patient care. Their impact on patient-centred outcomes in Australian and New Zealand ICUs is uncertain.

Objectives: To measure the association of these processes in ICU with in-hospital mortality.

Methods: The Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database and Critical Care Resources registry were used to extract patient-level factors, ICU-level factors and the year in which each process took place. Descriptive statistics and hierarchical logistic regression were used to determine the relationship between each process and in-hospital mortality.

Results: The study included 799 901 adults admitted to 173 ICUs from July 2009 to June 2016. The proportion of patients exposed to each process of care was 38.7% (antibiograms), 77.5% (AMS programmes) and 74.0% (ID rounds). After adjusting for confounders, patients admitted to ICUs that used ICU-specific antibiograms had a lower risk of in-hospital mortality [OR 0.95 (99% CI 0.92-0.99), P = 0.001]. There was no association between the use of AMS programmes [OR 0.98 (99% CI 0.94-1.02), P = 0.16] or routine rounds with ID physicians [OR 0.96 (99% CI 0.09-1.02), P = 0.09] and in-hospital mortality.

Conclusions: Use of ICU-specific antibiograms was associated with lower in-hospital mortality for patients admitted to ICU. For hospitals that do not perform ICU-specific antibiograms, their implementation presents a low-risk infection management process that might improve patient outcomes.
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http://dx.doi.org/10.1093/jac/dkab103DOI Listing
June 2021

Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method.

Crit Care 2021 03 16;25(1):106. Epub 2021 Mar 16.

Manchester University NHS Foundation Trust, Manchester, UK.

Background: Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice.

Methods: Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ) test (p < 0·05 was considered as unstable).

Results: Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16-24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment.

Conclusion: Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited.

Trial Registration: The study was registered with Clinical trials.gov Identifier: NCT04534569.
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http://dx.doi.org/10.1186/s13054-021-03491-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7962430PMC
March 2021

Acidemia subtypes in critically ill patients: An international cohort study.

J Crit Care 2021 08 26;64:10-17. Epub 2021 Feb 26.

Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Centre for Integrated Critical Care, Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia; Data Analytics Research and evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia.

Purpose: To study the prevalence, characteristic, outcome, and acid-base biomarker predictors of outcome for different acidemia subtypes.

Methods: We used national intensive care databases from three countries and classified acidemia subtypes as metabolic (standard base excess [SBE] < -2 mEq/L only), respiratory (PaCO > 42 mmHg only), and combined (both SBE < -2 mEq/L and PaCO > 42 mmHg) based on blood gas analysis in the first 24 h after ICU admission. To investigate acid-base predictors for hospital mortality, we applied the area under the receiver operating characteristic curve approach.

Results: We screened 643,689 ICU patients (2014-2018) and detected acidemia in 57.8%. The most common subtype was metabolic (42.9%), followed by combined (30.3%) and respiratory (25.9%). Combined acidemia had a mortality of 12.7%, compared with 11% for metabolic and 5.5% for respiratory. For combined acidemia, the best predictor of hospital mortality was pH. However, for metabolic or respiratory acidemia, it was SBE or PaCO, respectively.

Conclusions: In ICU patients with acidemia, mortality differs according to subtype and is highest in the combined subtype. Best acid-base predictors of mortality also differ according to subtype with best performance for pH in combined, SBE in metabolic, and PaCO in respiratory acidemia.
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http://dx.doi.org/10.1016/j.jcrc.2021.02.006DOI Listing
August 2021

Improving the predictability of time to death in controlled donation after circulatory death lung donors.

Transpl Int 2021 05 30;34(5):906-915. Epub 2021 Mar 30.

Lung Transplant Service, The Alfred Hospital and Monash University, Melbourne, Vic., Australia.

Although the use of donation after circulatory death (DCD) donors has increased lung transplant activity, 25-40% of intended DCD donors do not convert to actual donation because of no progression to asystole in the required time frame after withdrawal of cardiorespiratory support (WCRS). No studies have specifically focussed on DCD lung donor progression. This retrospective study reviewed intended DCD lung donors to make a prediction model of the likelihood of progression to death using logistic regression and classification and regression tree (CART). Between 2014 and 2018, 159 of 334 referred DCD donors were accepted, with 100 progressing to transplant, while 59 (37%) did not progress. In logistic regression, a length of ICU stay ≤ 5 days, severe infra-tentorial brain damage on imaging and use of vasopressin were related with the progression to actual donation. CART modelling of the likelihood of death within 90-minute post-WCRS provided prediction with a sensitivity of 1.00 and positive predictive value of 0.56 in the validation data set. In the nonprogressed DCD group, 26 died within 6 h post-WCRS. Referral received early after ICU admission, with nonspontaneous ventilatory mode, deep coma and severe infra-tentorial damage were relevant predictors. The CART model is useful to exclude DCD donor candidates with low probability of progression.
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http://dx.doi.org/10.1111/tri.13862DOI Listing
May 2021

Long-term Survival of Critically Ill Patients Stratified According to Pandemic Triage Categories: A Retrospective Cohort Study.

Chest 2021 08 9;160(2):538-548. Epub 2021 Mar 9.

Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia; Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia.

Background: The COVID-19 pandemic has led to unprecedented demand for ICUs, with the need to triage admissions along with the development of ICU triage criteria. However, how these criteria relate to outcomes in patients already admitted to the ICU is unknown, as is the incremental ICU capacity that triage of these patients might create given existing admission practices.

Research Question: What is the short- and long-term survival of low- vs high-priority patients for ICU admission according to current pandemic triage criteria?

Study Design And Methods: This study analyzed prospectively collected registry data (2007-2018) in 23 ICUs in Victoria, Australia, with probabilistic linkage with death registries. After excluding elective surgery, admissions were stratified according to existing ICU triage protocol prioritization as low (age ≥ 85 years, or severe chronic illness, or Sequential Organ Failure Assessment [SOFA] score = 0 or ≥ 12), medium (SOFA score = 8-11) or high (SOFA score = 1-7) priority. The primary outcome was long-term survival. Secondary outcomes were in-hospital mortality, ICU length of stay (LOS) and bed-day usage.

Results: This study examined 126,687 ICU admissions. After 5 years of follow-up, 1,093 of 3,296 (33%; 95% CI, 32-34) of "low-priority" patients aged ≥ 85 years or with severe chronic illness and 86 of 332 (26%; 95% CI, 24-28) with a SOFA score ≥ 12 were still alive. Sixty-three of 290 (22%; 95% CI, 17-27) of patients in these groups followed up for 10 years were still alive. Together, low-priority patients accounted for 27% of all ICU bed-days and had lower in-hospital mortality (22%) than the high-priority patients (28%). Among nonsurvivors, low-priority admissions had shorter ICU LOS than medium- or high-priority admissions.

Interpretation: Current SOFA score or age or severe comorbidity-based ICU pandemic triage protocols exclude patients with a close to 80% hospital survival, a > 30% five-year survival, and 27% of ICU bed-day use. These findings imply the need for stronger evidence-based ICU triage protocols.
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http://dx.doi.org/10.1016/j.chest.2021.03.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7941020PMC
August 2021

Annual prevalence, characteristics, and outcomes of intensive care patients with skin or soft tissue infections in Australia and New Zealand: A retrospective cohort study between 2006-2017.

Aust Crit Care 2021 09 1;34(5):403-410. Epub 2021 Mar 1.

Intensive Care Unit, Canberra Hospital, Yamba Dr, Garran, Australian Capital Territory, 2605, Australia; Medical School, Australian National University, Building 4, The Canberra Hospital, Hospital Rd, Garran, Australian Capital Territory, 2605, Australia; Faculty of Health, University of Canberra, 11 Kirninari Street, Bruce, Australian Capital Territory, 2617, Australia. Electronic address:

Background: There are limited published data on the epidemiology of skin and soft tissue infections (SSTIs) requiring intensive care unit (ICU) admission. This study intended to describe the annual prevalence, characteristics, and outcomes of critically ill adult patients admitted to the ICU for an SSTI.

Methods: This was a registry-based retrospective cohort study, using data submitted to the Australian and New Zealand Intensive Care Society Adult Patient Database for all admissions with SSTI between 2006 and 2017. The inclusion criteria were as follows: primary diagnosis of SSTI and age ≥16 years. The exclusion criteria were as follows: ICU readmissions (during the same hospital admission) and transfers from ICUs from other hospitals. The primary outcome was in-hospital mortality, and the secondary outcomes were ICU mortality and length of stay (LOS) in the ICU and hospital with independent predictors of outcomes.

Results: Admissions due to SSTI accounted for 10 962 (0.7%) of 1 470 197 ICU admissions between 2006 and 2017. Comorbidities were present in 25.2% of the study sample. The in-hospital mortality was 9% (991/10 962), and SSTI necessitating ICU admission accounted for 0.07% of in-hospital mortality of all ICU admissions between 2006 and 2017. Annual prevalence of ICU admissions for SSTI increased from 0.4% to 0.9% during the study period, but in-hospital mortality decreased from 16.1% to 6.8%. The median ICU LOS was 2.1 days (interquartile range = 3.4), and the median hospital LOS was 12.1 days (interquartile range = 20.6). ICU LOS remained stable between 2006 and 2017 (2.0-2.1 days), whereas hospital LOS decreased from 15.7 to 11.2 days. Predictors for in-hospital mortality included Australian and New Zealand Risk of Death scores [odds ratio (OR): 1.07; confidence interval (CI) (1.05, 1.09); p < 0.001], any comorbidity except diabetes [OR: 2.00; CI (1.05, 3.79); p = 0.035], and admission through an emergency response call [OR: 2.07; CI (1.03, 4.16); p = 0.041].

Conclusions: SSTIs are uncommon as primary ICU admission diagnosis. Although the annual prevalence of ICU admissions for SSTI has increased, in-hospital mortality and hospital LOS have decreased over the last decade.
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http://dx.doi.org/10.1016/j.aucc.2020.10.013DOI Listing
September 2021

Linkage of Australian national registry data using a statistical linkage key.

BMC Med Inform Decis Mak 2021 02 2;21(1):37. Epub 2021 Feb 2.

Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.

Background: Data from clinical registries may be linked to gain additional insights into disease processes, risk factors and outcomes. Identifying information varies from full names, addresses and unique identification codes to statistical linkage keys to no direct identifying information at all. A number of databases in Australia contain the statistical linkage key 581 (SLK-581). Our aim was to investigate the ability to link data using SLK-581 between two national databases, and to compare this linkage to that achieved with direct identifiers or other non-identifying variables.

Methods: The Australian and New Zealand Society of Cardiothoracic Surgeons database (ANZSCTS-CSD) contains fully identified data. The Australian and New Zealand Intensive Care Society database (ANZICS-APD) contains non-identified data together with SLK-581. Identifying data is removed at participating hospitals prior to central collation and storage. We used the local hospital ANZICS-APD data at a large single tertiary centre prior to deidentification and linked this to ANZSCTS-CSD data. We compared linkage using SLK-581 to linkage using non-identifying variables (dates of admission and discharge, age and sex) and linkage using a complete set of unique identifiers. We compared the rate of match, rate of mismatch and clinical characteristics between unmatched patients using the different methods.

Results: There were 1283 patients eligible for matching in the ANZSCTS-CSD. 1242 were matched using unique identifiers. Using non-identifying variables 1151/1242 (92.6%) patients were matched. Using SLK-581, 1202/1242 (96.7%) patients were matched. The addition of non-identifying data to SLK-581 provided few additional patients (1211/1242, 97.5%). Patients who did not match were younger, had a higher mortality risk and more non-standard procedures vs matched patients. The differences between unmatched patients using different matching strategies were small.

Conclusion: All strategies provided an acceptable linkage. SLK-581 improved the linkage compared to non-identifying variables, but was not as successful as direct identifiers. SLK-581 may be used to improve linkage between national registries where identifying information is not available or cannot be released.
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http://dx.doi.org/10.1186/s12911-021-01393-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856707PMC
February 2021

Optimising a targeted test reduction intervention for patients admitted to the intensive care unit: The Targeted Intensive Care Test Ordering Cluster Trial intervention.

Aust Crit Care 2021 09 30;34(5):419-426. Epub 2021 Jan 30.

Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia.

Background: Approaches to routine diagnostic testing in the intensive care unit include time-scheduled testing and targeted testing. Blood tests and chest radiographs requested on a routine, time-scheduled basis may reduce the risk of missing important findings. Targeted testing, considering individual patient needs, may reduce unnecessary testing, wasted clinician time, and costs. However, existing evidence of targeted testing interventions is generally of low quality, and the optimal testing approach is uncertain.

Objectives: The aim of the study was to describe the development of an intervention to reduce unnecessary diagnostic test ordering by clinicians working in intensive care, with the aim of informing the design of a pivotal clinical trial.

Methods: The Capability, Opportunity, Motivation-Behaviour model was used as a theoretical framework for change. The intervention components were informed by systematically identifying, assessing, and classifying targeted testing interventions in behavioural terms. Feedback from intensive care clinicians and patients was sought using surveys and a consumer reference group.

Results: The mean percentage of routine tests considered unnecessary by 201 intensive care clinicians was 33 (standard deviation = 16). When presented with a statement of the pros and cons for targeted versus liberal testing (n = 154), 93 (60%) consumer survey respondents preferred a more liberal approach, 33 (21%) preferred a more restrictive approach, and 28 (18%) were unsure. There were 24 behavioural interventions identified and incorporated into the final intervention. This had five major components: (i) a management committee to acquire, disseminate, and coordinate intervention-related information, (ii) a targeted testing guideline for sites, (iii) educational material for sites, (iv) site medical and nursing champions, and (v) site audit and feedback.

Conclusions: Although surveyed intensive care clinicians report substantial unnecessary routine diagnostic testing, on the basis of currently available evidence, consumers prefer a more liberal approach. This feedback, and a framework to identify behavioural interventions, has been used to inform the design of a proposed targeted testing clinical trial.
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http://dx.doi.org/10.1016/j.aucc.2020.11.003DOI Listing
September 2021

Learning from the First Wave of the Pandemic in England, Wales, and Northern Ireland.

Am J Respir Crit Care Med 2021 03;203(5):532-534

Department of Intensive Care The Alfred Hospital Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1164/rccm.202101-0089EDDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7924580PMC
March 2021
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