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

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

A comparison of survival following out-of-hospital cardiac arrest in Sydney, Australia, between 2004-2005 and 2009-2010.

OBJECTIVE: To determine whether survival following out-of- hospital cardiac arrest (OHCA) in Sydney, Australia, improved between 2004-2005 and 2009-2010, and whether there was a change in incidence of OHCA. DESIGN: Retrospective study using the Ambulance Service of New South Wales and NSW Registry of Births, Deaths and Marriages databases. PARTICIPANTS AND SETTING: All patients who had an OHCA in the Sydney metropolitan area and who used the Ambulance Service of NSW between June 2009 and May 2010 (2009-2010), and between June 2004 and May 2005 (2004-2005). MAIN OUTCOME MEASURES: Survival to 90 days. Other outcome measures included the incidence of OHCA and survival to the day following OHCA, 28 days and 1 year following OHCA. Survival and incidence were also calculated according to initial electrocardiograph rhythm. RESULTS: Survival to 90 days was 12.3% in 2004-2005 and 10.2% in 2009-2010 (P = 0.015). In 2004-2005, the age standardised incidence of OHCA was 52.6 events per 100 000 person-years (95% CI, 51.6-53.6 events per 100 000 person-years), and in 2009-2010 it was 48.4 events per 100 000 person-years (95% CI, 46.3-50.4 events per 100 000 person-years). In 2004-2005, the incidence of ventricular fibrillation (VF) was 31.3% (95% CI, 28.4%- 33.9%) and in 2009-2010 it was 22.1% (95% CI, 20.0%- 24.3%). CONCLUSION: There was no improvement in survival following OHCA in Sydney between 2004-2005 and 2009- 2010. There has been a decrease in overall survival from OHCA and a decrease in the overall age-standardised incidence of OHCA. The decrease in overall survival may be due to a decline in the incidence of VF.

The effect of endotracheal tube size on voice and swallowing function in patients with thermal burn injury: an evaluation using the Australian Therapy Outcome Measures (AusTOMS).

The objective of this study was to determine if intubation using larger endotracheal tube sizes in mechanically ventilated patients with thermal burn injury adversely affects voice and swallowing function. This prospective, observational study was conducted in patients with thermal burn injuries, who were mechanically ventilated via an endotracheal tube. The primary outcome measures were changes in voice and swallowing function, assessed using the Australian Therapy Outcome Measures (AusTOMS), immediately before the burn injury, and 12 months after the removal of the endotracheal tube. Of 101 patients screened, 20 male patients were followed for 12 months. Patients intubated with size 8.0 or larger endotracheal tubes were compared to patients with size 7.5 endotracheal tubes or smaller. Patients with the larger endotracheal tubes had a significant 1.8-point (9%) decline in their AusTOMS voice score (p =.01) using the paired t-test, but there was no significant difference between the two groups using the independent samples t-test. There was no significant difference in swallowing outcome between the two groups. Male patients with thermal burn injuries, mechanically ventilated using size 8.0 endotracheal tubes or larger, had a statistically significant decline in voice outcome; however, interpretation of this result is limited by methodological considerations.

Development and evaluation of an influenza pandemic intensive care unit triage protocol.

OBJECTIVES: To develop an influenza pandemic ICU triage (iPIT) protocol that excludes patients with the highest and lowest predicted mortality rates, and to determine the increase in ICU bed availability that would result. DESIGN AND SETTING: Post-hoc analysis of a study evaluating two triage protocols, designed to determine which patients should be excluded from access to ICU resources during an influenza pandemic. ICU mortality rates were determined for the individual triage criteria in the protocols and included criteria based on the Sequential Organ Failure Assessment (SOFA) score. Criteria resulting in mortality rates outside the 25th and 75th percentiles were used as exclusion criteria in a new iPIT-1 protocol. The SOFA threshold component was modified further and reported as iPIT-2 and iPIT-3. MAIN OUTCOME MEASURE: Increase in ICU bed availability. RESULTS: The 25th and 75th percentiles for ICU mortality were 8.3% and 35.2%, respectively. Applying the iPIT-1 protocol resulted in an increase in ICU bed availability at admission of 71.7% ± 0.6%. Decreasing the lower SOFA score exclusion criteria to ≤6 (iPIT-2) and ≤4 (iPIT-3) resulted in an increase in ICU bed availability at admission of 66.9% ± 0.6% and 59.4 ± 0.7%, respectively (P < 0.001). CONCLUSION: The iPIT protocol excludes patients with the lowest and highest ICU mortality, and provides increases in ICU bed availability. Adjusting the lower SOFA score exclusion limit provides a method of escalation or de- escalation to cope with demand.

A multicentre evaluation of two intensive care unit triage protocols for use in an influenza pandemic.

OBJECTIVE: To determine the increase in intensive care unit (ICU) bed availability that would result from the use of the New South Wales and Ontario Health Plan for an Influenza Pandemic (OHPIP) triage protocols. DESIGN, SETTING AND PATIENTS: Prospective evaluation study conducted in eight Australian, adult, general ICUs, between September 2009 and May 2010. All patients who were admitted to the ICU, excluding those who had elective surgery, were prospectively evaluated using the two triage protocols, simulating a pandemic situation. Both protocols were originally developed to determine which patients should be excluded from accessing ICU resources during an influenza pandemic. MAIN OUTCOME MEASURE: Increase in ICU bed availability. RESULTS: At admission, the increases in ICU bed availability using Tiers 1, 2 and 3 of the NSW triage protocol were 3.5%, 14.7% and 22.7%, respectively, and 52.8% using the OHPIP triage protocol (P < 0.001). Re-evaluation of patients at 12 hours after admission using Tiers 1, 2 and 3 of the NSW triage protocol incrementally increased ICU bed availability by 19.2%, 16.1% and 14.1%, respectively (P < 0.001). The maximal cumulative increases in ICU bed availability using Tiers 1, 2 and 3 of the NSW triage protocol were 23.7%, 31.6% and 37.5%, respectively, at 72 hours (P < 0.001), and 65.0% using the OHPIP triage protocol, at 120 hours (P < 0.001). CONCLUSION: Both triage protocols resulted in increases in ICU bed availability, but the OHPIP protocol provided the greatest increase overall. With the NSW triage protocol, ICU bed availability increased as the protocol was escalated.

Expansion of a medical emergency team system to a mental health facility.

BACKGROUND: Clinical emergency response systems such as medical emergency teams (MET) are used in many hospitals worldwide, but the effect that these systems have in mental health facilities is unknown. This study examined the rate and nature of MET calls to a mental health facility that had relocated to the campus of a tertiary referral hospital. METHODS: This study was a prospective, observational study of MET calls to a newly constructed 170 bed mental health facility. Data were collected on the number and nature of MET calls to the facility. RESULTS: Over 24 months, there were 66 MET calls to the mental health facility, and 1217 MET calls at the main hospital. The mean MET call rate was 14.2 calls per 1000 admissions (95% confidence interval (CI) 10.8-17.7) at the mental health facility, and 14.7 calls per 1000 admissions (95% CI 13.9-15.5) at the main hospital. Neurological and cardiovascular problems were present in 61% and 41% of MET calls. CONCLUSION: The rate of MET calls to a new mental health facility can be similar to that of a tertiary hospital. Staff attending MET calls need to be prepared to manage predominantly neurological and cardiovascular problems.

Palliative care teams in the intensive care unit: a randomised, controlled, feasibility study.

OBJECTIVES: To determine whether palliative care teams can improve patient, family and staff satisfaction for patients receiving end-of-life care in the intensive care unit and reduce surrogate markers of health care costs. DESIGN: Randomised controlled, feasibility study. SETTING: 14-bed general ICU over 29 months in 2006-2008. PARTICIPANTS: Patients admitted with a terminal or preterminal condition, for whom the treating intensivist considered that escalating or continuing treatment was unlikely to achieve significant improvement in the patient's clinical condition. INTERVENTION: A consultation from a palliative care team, in addition to usual ICU end-of-life care. MAIN OUTCOME MEASURES: ICU and hospital length of stay, and changes in composite scores of satisfaction obtained from questionnaires administered to families, nursing staff and intensivists. RESULTS: The study was constrained by significant logistical and methodological problems, including low recruitment and questionnaire completion rates, and the lack of an available validated questionnaire. From a total of 2009 admissions over a 29-month period, 20 patients were enrolled, 10 in each group. There were significant differences in baseline characteristics. There were no statistically significant differences between those who had a consultation with the palliative care team and those who did not in median ICU length of stay (3 days v 5 days, P=0.97), median hospital length of stay (5 days v 11 days, P=0.44), or changes in overall composite satisfaction scores reported by families (-6% v -6%, P=0.91), nursing staff (+5% v +15%, P=0.30), and intensivists (-2% v +2%, P=0.42). CONCLUSION: This feasibility study was difficult to conduct and did not generate any robust conclusions about the utility of involving palliative care teams in end-of-life care in the ICU. Larger studies are technically possible but unlikely to be feasible. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN012606000110583.

Injuries occurring in hospital staff attending medical emergency team (MET) calls--a prospective, observational study.

BACKGROUND: Clinical emergency response systems such as medical emergency teams (MET) have been implemented in many hospitals worldwide, but the effect that these systems have on injuries to hospital staff is unknown. The objective of this study was to determine the rate and nature of injuries occurring in hospital staff attending MET calls. METHODS: This study was a prospective, observational study, using a structured interview, of 1265 MET call participants, in a 650 bed urban, teaching hospital. Data was collected on the number and the nature of injuries occurring in hospital staff attending MET calls. RESULTS: Over 131 days, 248 MET calls were made. An average of 8.1 staff participated in each MET call. The overall injury rate was 13 (95% confidence interval (CI) 7-20) per 1000 MET participant attendances, and 70 (95% CI 38-102) per 1000 MET calls. One injured participant required time off-work, an injury requiring time off-work rate of 1 (95% CI 0-4) per 1000 MET participant attendances, or 4 (95% CI 0-27) per 1000 MET calls. The relative risk of sustaining an injury if the MET participant performed chest compressions, contacted patient body fluids on clothing or protective equipment, without direct contact to skin or mucosa, or lifted the patient or a patient body part was 11.0 (95% CI 4.2-28.6), 8.7 (95% CI 3.4-22.0) and 5.5 (95% CI 2.1-14.2), respectively. CONCLUSION: The rate of injuries occurring to hospital staff attending MET calls is relatively low, and many injuries could be considered relatively minor.

Operator anaesthesiology training and complications after endotracheal intubation in the intensive care unit: a 3-year, prospective, observational study.

OBJECTIVE: To determine whether operators with less than 3 months' formal anaesthesiology training have higher rates of complications when performing endotracheal intubation (ETI) in the intensive care unit than operators with longer formal anaesthesiology training. DESIGN AND SETTING: Prospective, single-centre, observational study of consecutive ETIs performed in a general, urban, tertiary ICU between May 2005 and May 2008. Data were collected by self-reported, written questionnaire. PARTICIPANTS: The two pre-defined study cohorts were ETIs performed where the initial operator had less than 3 months' formal training in anaesthesiology, and those where the initial operator had 3 months' or longer training. MAIN OUTCOME MEASURES: The primary outcome measure was the number of ETIs where one or more pre-defined complications occurred as a result of the ETI. Secondary outcome measures were the number of ETIs where one or more respiratory, cardiovascular or trauma complications occurred as a result of the ETI, and the number where the airway was deemed difficult by the operator. RESULTS: Data were collected on 276 ETIs. There were no significant differences in primary or secondary outcome measures between the two main study groups. Operators with less than 3 months' formal training in anaesthesiology had a higher level of medical supervision or assistance (75% v 29%, P<0.001), more favourable patient pre-intubation oxygen saturation on pulse oximetry (SpO(2)) (76% v 65% had SpO(2)>89%, P=0.05), and easier resultant grade of intubation (70% v 56% of intubations were Grade I, P= 0.04), but required more operators (19% v 3% required two operators, P<0.001), and more attempts before ETI was successful (62% v 82% of intubations were successful on first attempt, P<0.001). CONCLUSION: ETIs performed in the ICU where the initial operator has less than 3 months' formal training in anaesthesiology appear not to be associated with more complications. However, this may be attributable to less experienced operators having more assistance and supervision, and to patient selection.

Effect of implementation of a weekly multidisciplinary team meeting in a general intensive care unit.

OBJECTIVE: To determine whether the introduction of a weekly multidisciplinary team meeting (MDTM) to a general intensive care unit improved selected clinical indicators of patient outcome, and staff satisfaction with patient care. DESIGN: A single-centre, observational, before-and-after study. SETTING: A 14-bed general ICU in an urban, tertiary teaching hospital. STUDY POPULATION: All patients admitted to the ICU during June-December 2006 (before the intervention) and June- December 2007 (after the intervention), and staff employed in the ICU in December 2006 and December 2007. INTERVENTION: Introduction of a weekly MDTM to the ICU. MAIN OUTCOME MEASURES: The primary outcome was the number of patients who stayed in the ICU longer than 5 days. Secondary outcomes included nurses' scores for satisfaction with patient care on a questionnaire; ICU and hospital mortality; duration of mechanical ventilation; readmissions to the ICU within 72 hours of discharge; and after-hours discharges. RESULTS: There were 376 ICU admissions in the "before" period and 432 in the "after" period. Baseline characteristics of the two groups were similar except for a lower proportion of patients admitted directly to the ICU from the operating theatres in the after period (34.2% v 45.2%, P = 0.002). There were no significant differences in any of the primary or secondary outcomes, with the exception of one questionnaire score: a fall in the score nursing staff gave for value of all meetings held in the ICU following the introduction of the MDTM (from 6.6 to 3.9 on a scale of 0-10, P = 0.001). CONCLUSION: The introduction of a weekly MDTM to a general ICU did not improve selected clinical indicators of patient outcome or staff satisfaction with patient care.

Survival after out-of-hospital cardiac arrest in Sydney, Australia.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a significant cause of death, but there is little published information on its incidence and outcomes in Australia. AIM: This study was undertaken to determine the incidence and survival from OHCA in Sydney, New South Wales. METHODS: Patients listed on the Ambulance Service of NSW database as having an OHCA during the 12-month period 1 June 2004 to 31 May 2005 were matched with the NSW Registry of Births, Deaths and Marriages to determine if they had died, and how long they survived. Survival was also determined for patients aged 80 years or older, and for the presenting electrocardiograph (ECG) rhythm. RESULTS: OHCAs were recorded for 2011 people in a population of 3.993 million. The age-standardised incidence was 52.6 events per 100,000 person-years (95% CI, 51.6-53.6). Incidence was significantly higher in older age groups. Only 24% of patients survived past the day of the OHCA. Survival for 28 days, 90 days and 1 year was 12.6%, 12.2%, and 11.5%, respectively. Survival was highest when the presentation ECG was ventricular fibrillation. Patients aged 80 years or older had lower survival rates. CONCLUSION: Survival from OHCA in Sydney is low, and lower in patients aged 80 years or older. The incidence of OHCA in Sydney is similar to that in the rest of the world. Mortality occurs early after OHCA. Hence, for interventions to be effective in improving survival, they need to be targeted at the early stages of OHCA.

A rapidly fatal case of T-cell lymphoma presenting as idiopathic orbital inflammation.

A 41-year-old Caucasian woman presented with a painful, red right eye with minimal systemic symptomatology, and was initially diagnosed with right idiopathic orbital inflammation. Ten days later, she developed abdominal and respiratory symptoms; this led to her demise within a further week. Post-mortem examination demonstrated widespread extranodal NK/T- cell lymphoma (nasal type), involving the right posterior orbit, lungs, uterus, left adrenal gland, pericardium and meninges. Thorough physical examination with early orbital biopsy should be considered to exclude underlying treatable pathology in managing patients with presumed idiopathic orbital inflammation.

Fatal leptospirosis presenting as musculoskeletal chest pain.

After holidaying in Vanuatu, a 24-year-old man presented with pleuritic chest pain and chest wall tenderness thought to be musculoskeletal in origin. He developed fatal acute renal failure, jaundice, respiratory failure, myocarditis and rhabdomyolysis. Subsequent serological results showed a rise in serum titre of antibodies to Leptospira grippotyphosa, from 1 : 50 to 1 : 800, consistent with acute infection.