Implementing antimicrobial stewardship in the Australian private hospital system: a qualitative study.

OBJECTIVE: To explore organisational factors and barriers contributing to limited uptake of antimicrobial stewardship (AMS) in Australian private hospitals and to determine solutions for AMS implementation. METHODS: A qualitative study using a series of focus group discussions was conducted in a large private hospital making use of a semistructured interview guide to facilitate discussion among clinical and non-clinical stakeholders. A thematic analysis using five sequential components that mapped and interpreted emergent themes surrounding AMS implementation was undertaken by a multidisciplinary team of researchers. RESULTS: Analysis revealed that autonomy of consultant specialists was perceived as being of greater significance in private hospitals compared with public hospitals. Use of an expert team providing antimicrobial prescribing advice and education without intruding on existing patient-specialist relationships was proposed by participants as an acceptable method of introducing AMS in private hospitals. There was more opportunity for nursing and pharmacist involvement, as well as empowering patients. Opportunities were identified for the hospital executive to market an AMS service as a feature that promoted excellence in patient care. CONCLUSIONS: Provision of advice from experts, championing by clinical leaders, marketing by hospital executives and involving nurses, pharmacists and patients should be considered during implementation of AMS in private hospitals.

Venous thromboembolism prophylaxis in the critically ill: a point prevalence survey of current practice in Australian and New Zealand intensive care units.

BACKGROUND: Critically ill patients are at high risk of morbidity and mortality caused by venous thromboembolism (VTE). In addition to premorbid predisposing conditions, critically ill patients may be exposed to prolonged immobility, invasive intravascular catheters and frequent operative procedures, and further may have contraindications to pharmaceutical prophylactic measures designed to attenuate VTE risk. There are limited data describing current VTE prophylaxis regimens in Australia and New Zealand. OBJECTIVE: To document current Australian and New Zealand management of VTE prophylaxis in a large mixed cohort of critically ill patients. DESIGN: Prospective, multicentre point prevalence survey endorsed by the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS CTG). SETTING: 30 public hospital ICUs in Australia and New Zealand surveyed on Wednesday 9 May 2007. METHODS: For all patients in each ICU on the study day, demographic data, admission diagnosis and information on VTE prophylaxis were prospectively collected. RESULTS: 502 patients were included in the survey, and 431 of these (86%) received VTE prophylaxis. Of these, 64% (276/431) received pharmacological prophylaxis and 80% (345/431) received mechanical prophylaxis, with 44% (190/431) receiving both. Of those receiving pharmacological prophylaxis, unfractionated heparin was used in 74%, and enoxaparin (low molecular weight heparin) in 23%. Contraindications to pharmacological prophylaxis were reported in 122 patients. Overall, pharmacological prophylaxis was administered to 87% of potentially suitable patients. CONCLUSIONS: We observed a high prevalence of VTE prophylaxis, with many critically ill patients receiving two or more modalities of prophylaxis. These results show that the potential risk of VTE in critically ill patients is recognised in Australia and New Zealand, and strategies to mitigate this serious complication are widely implemented.

Antibiotic prophylaxis for cardiac surgery in Australia.

OBJECTIVE: To evaluate national practice for antibiotic prophylaxis in cardiac surgery with respect to the use of protocols, agent selection and duration of administration. DESIGN, SETTING AND PARTICIPANTS: Two point-prevalence surveys of intensive care units in 24 public and 27 private hospitals performing cardiac surgery in Australia, conducted in 2004 and 2008, using a structured telephone questionnaire of the attending senior intensive care clinician in each unit. MAIN OUTCOME MEASURES: Existence of a protocol in the unit for antibiotic prophylaxis, specific antibiotic agents used and their duration of administration. RESULTS: Between 2004 and 2008, reported protocol use increased from 58% to 80% (P = 0.02), while concordance with version 13 of the Australian Therapeutic guidelines: antibiotic for both choice of agent and timing (duration of administration) remained around 10%. Use of multiple agents was common, as was continued antibiotic administration after completion of surgery. Over 4 years, the proportion of cardiac surgical units reporting vancomycin administration for routine valve surgery prophylaxis doubled to 62% (P < 0.001). CONCLUSION: Despite an increase in reported protocol use for antibiotic prophylaxis in cardiac surgery, concordance with national antibiotic guidelines remained low, with duration of antibiotic administration deviating most from recommendations. Prophylactic vancomycin use appears to have increased substantially in recent years. Clinical implementation of recommended perioperative cardiac surgical antibiotic prophylaxis may not occur until supported by evidence from either a large prospective randomised study or standardised national surveillance of cardiac surgical site infection rates.

Documentation of clinical review and vital signs after major surgery.

OBJECTIVE: To describe the quality of postoperative documentation of vital signs and of medical and nursing review and to identify the patient and hospital factors associated with incomplete documentation. DESIGN, SETTING AND PARTICIPANTS: Retrospective audit of medical records of 211 adult patients following major surgery in five Australian hospitals, August 2003--July 2005. MAIN OUTCOME MEASURES: Proportion of patients with complete documentation of medical review (each day) and nursing review and vital signs (heart rate, blood pressure, respiratory rate, temperature and oxygen saturation) (each nursing shift), and the proportion of available opportunities for medical and nursing review where documentation was incomplete. Univariate and multivariate odds ratios for the association between incomplete documentation and hospital and patient factors. RESULTS: During the first 3 postoperative ward days, 17% of medical records had complete documentation of vital signs and medical and nursing review. During the first 7 postoperative ward days, nursing review was undocumented for 5.6% of available shifts and medical review for 14.9% of available days. Respiratory rate was the most commonly undocumented observation (15.4% undocumented). Certain hospitals were significantly associated with incomplete documentation. Vital signs were more commonly undocumented in patients without epidural or patient-controlled (PC) analgesia, during evening nursing shifts, and during successive postoperative ward days. Nursing review was more commonly undocumented in the evening and for patients without epidural or PC analgesia. Medical review was more commonly undocumented on weekends. CONCLUSION: Hospital and patient factors are associated with incomplete documentation of clinical review and vital signs after major surgery.

Critically ill obstetric patients in Australia: a retrospective audit of 8 years' experience in a tertiary intensive care unit.

OBJECTIVE: To review the indications for admission, demographics, clinically relevant aspects of medical care and outcomes of critically ill obstetric patients admitted to a tertiary hospital intensive care unit. DESIGN: Retrospective review. SETTING AND PARTICIPANTS: General medical and surgical ICU of a tertiary university-affiliated hospital in central Melbourne, Victoria, Australia. Medical records were reviewed for all women who were admitted to the ICU between January 1998 and June 2006 and were pregnant or within the 6-week postpartum period. All were transferred from other hospitals. MAIN OUTCOME MEASURES: Primary diagnoses, clinical indications for ICU admission, ICU interventions, and maternal and fetal outcomes. RESULTS: Over the 102-month period, 56 obstetric patients were admitted to the ICU (0.38% of all ICU admissions). Their mean (+/-SD) age was 31.8 (+/-5.76) years. All but two admissions were postpartum. The most common indications for ICU admission were haemodynamic instability (38%), respiratory complications (29%) and neurological complications (27%). Mechanical ventilatory support was required by 61% (34/56) of the patients, and blood transfusion by 48%. The median length of ICU stay was 45.75 hours (range, 8-281 hours). There were no maternal deaths, but residual functional or physical disability was noted in eight patients. There were four perinatal deaths. CONCLUSIONS: This audit is a reminder that continued vigilance is required to ensure maternal safety. It also emphasises the need to integrate free-standing maternity units with hospital intensive care services.

Acute stress ulceration prophylaxis: point prevalence surveys in intensive care units in Victoria, 1997 and 2005.

OBJECTIVE: To assess current practice in acute stress ulceration (ASU) prophylaxis in adult intensive care units in Victoria, Australia, in 1997 and 2005. METHODS: Point prevalence surveys using a structured telephone questionnaire of ASU prophylaxis practices were performed in adult ICUs in Victoria on 11 November 1997 and 13 April 2005. RESULTS: All Victorian ICUs identified on each study day participated, comprising 30 ICUs in 1997 and 35 ICUs in 2005. Presence of a clinical protocol or guideline for ASU prophylaxis increased significantly from 23% in 1997 to 54% in 2005 (P = 0.01). Overall provision of ASU prophylaxis to ICU patients also increased significantly from 67% in 1997 to 86% in 2005 (P < 0.001). H2-receptor antagonists were the preferred first-line agent in at least 50% of ICUs, and were also the most commonly used agents in both point prevalence surveys, with no change over 8 years. Use of proton-pump inhibitors increased significantly, both as first-line ASU prophylaxis agents and in clinical use, from 13% in 1997 to 45% in 2005 (P < 0.001). Use of sucralfate and antacids for ASU prophylaxis ceased between 1997 and 2005. CONCLUSIONS: Use of ASU prophylaxis for patients admitted to Victorian ICUs increased significantly from 1997 to 2005, with an associated increase in the presence of protocols or guidelines for ASU prophylaxis. Although agents currently used for ASU prophylaxis in Victorian ICUs are consistent with available evidence, we are concerned that ASU prophylaxis is given to all patients admitted to the ICU rather than targeted to patients in high-risk categories.

Heparin: the cheap alternative for immunomodulation in sepsis?

Severe sepsis, involving a systemic inflammatory response caused by infection and acute organ dysfunction, is one of the most common non-cardiac causes of death in intensive care unit patients worldwide. The mainstay of treatment for severe sepsis is aggressive antibiotic therapy combined with supportive care for associated organ dysfunction. In 2001, recombinant human activated protein C was shown to improve survival in patients with severe sepsis, but two further studies of the immunomodulatory effects of endogenous anticoagulant agents did not show any survival benefit. Importantly, all three studies showed potential confounding by patients receiving low-dose heparin during the study period, raising the possibility that heparin may also have important immunomodulatory actions. This has increased the focus on the non-anticoagulatory actions of heparin, and its potential therapeutic immunodulatory effects during severe sepsis. This review summarises the known clinical effects of heparin and explores the significant implications of its widespread therapeutic use.

Helicobacter pylori in intensive care: why we should be interested.

Helicobacter pylori is estimated to infect over 50% of the world's population, the majority of whom are asymptomatic. Although most research to date has focused on local gastroduodenal disease manifestations, the potential impact of H. pylori infection and the associated chronic active inflammation on systemic disease processes is now being explored. This review addresses three aspects of emerging importance regarding H. pylori in intensive care medicine: acute gastric stress ulceration, nosocomial infection, and the potential modulatory effect on the systemic stress response. The role of H. pylori in acute stress ulceration remains uncertain, but it is unlikely to have the same major aetiological role as in peptic ulcer disease. The pathogenesis of both acute stress ulceration and H. pylori gastritis suggest overlapping mechanisms of gastric mucosal damage and H. pylori may augment stress ulceration incidence and severity. Nosocomial infection of both staff and patients with H. pylori has been suggested by serological studies, and increased H. pylori infection has been reported in intensive care staff. This has significant short- and long-term health implications and also raises questions regarding the efficacy and implementation of routine infection control precautions in intensive care. Finally, H. pylori infection has been linked with the pathogenesis of many extra-intestinal diseases, but the evidence is weak and the relationship between H. pylori and systemic diseases remains controversial. However, the potential for H. pylori to modulate systemic disease processes, particularly the systemic stress response in critical illness, is both theoretically plausible and therapeutically tantalising and requires further investigation.