The Canberra Hospital Intensive Care Research Group provided funding for the AIHW NDI linkage.

Introduction: Mobilisation of intensive care (ICU) patients leads to better outcomes, including reduced mechanical ventilation duration, shorter length of ICU stay, and lower risk of readmission and mortality. However, international point prevalence studies reveal that ICU mobilisation rates are low, even when services are fully staffed on weekdays. In our ICU, mobilisation practice is well-established (54% of patient days) and involves a multidisciplinary approach including physiotherapists and nurses. Physiotherapy services are reduced over weekends (2.6 FTE to 1.0FTE), with the impact on mobilisation rates unknown.

Introduction: The diagnosis of sepsis in the retrieval setting has proved problematic, potentially leading to suboptimal patient care. The recent redefinition of sepsis brought with it the introduction of the quick Sepsis Related Organ Failure Assessment (qSOFA), a set of simple criteria designed to detect septic patients.

Introduction: Mobilisation of intensive care (ICU) patients reduces ICU and hospital length of stay, attenuates ICU-acquired weakness, and reduces mortality 12 months post-discharge. Despite these benefits, the prevalence of mobilisation in ICU is low (12–54%). In 2012 we showed that our mobilisation rate at The Canberra Hospital (TCH) was high (54%) and our barriers to mobilisation included avoidable factors such as femoral lines and timing of procedures. These barriers may have changed with time and staff turnover.

Introduction: Mobilisation of ICU patients reduces ICU-acquired weakness and is associated with better functional outcomes. However, the prevalence of mobilisation of ICU patients remains low. A known barrier to mobilisation is haemodynamic instability, frequently with patients requiring vasoactive infusions. There are little data to guide clinicians about the feasibility of mobilising ICU patients receiving vasoactive infusions.

Patients who come to the intensive care unit are amongst the sickest patients in our hospitals. Patients can be admitted to the intensive care unit unexpectedly (following accidents or sudden onset of illness) or as unplanned but not necessarily truly 'unexpected' admissions. These patients often have significant underlying chronic health issues, including metastatic cancer, advanced cardiac, respiratory, renal, or hepatic failure, or frailty, with a high likelihood of death in the ensuing months. Using the Australian and New Zealand Intensive Care Society Clinical Trials Group Point Prevalence Program, a prospective single day observational study across 46 Australian hospitals in 2014 and 2015, we found that less than 9% of intensive care unit patients (51/577) had an advance directive available. From these results, we provide two suggestions to increase intensive care's understanding of patients' end-of-life wishes. First, systematically target 'high risk of dying' patient groups for goals of care conversations in the outpatient setting. Such groups include those where one would not be 'surprised' if they died within a year. Second, as a society, more conversations about end-of-life wishes are needed.

PURPOSETo investigate the extent of objective 'non-beneficial treatments (NBTs)' (too much) anytime in the last 6 months of life in routine hospital care.DATA SOURCESEnglish language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995-April 2015).STUDY SELECTIONAll study types assessing objective dimensions of non-beneficial medical or surgical diagnostic, therapeutic or non-palliative procedures administered to older adults at the end of life (EOL).DATA EXTRACTIONA 13-item quality score estimated independently by two authors.RESULTS OF DATA SYNTHESISEvidence from 38 studies indicates that on average 33-38% of patients near the EOL received NBTs. Mean prevalence of resuscitation attempts for advanced stage patients was 28% (range 11-90%). Mean death in intensive care unit (ICU) was 42% (range 11-90%); and mean death rate in a hospital ward was 44.5% (range 29-60%). Mean prevalence of active measures including dialysis, radiotherapy, transfusions and life support treatment to terminal patient was 7-77% (mean 30%). Non-beneficial administration of antibiotics, cardiovascular, digestive and endocrine treatments to dying patients occurred in 11-75% (mean 38%). Non-beneficial tests were performed on 33-50% of patients with do-not-resuscitate orders. From meta-analyses, the pooled prevalence of non-beneficial ICU admission was 10% (95% CI 0-33%); for chemotherapy in the last six weeks of life was 33% (95% CI 24-41%).CONCLUSIONThis review has confirmed widespread use of NBTs at the EOL in acute hospitals. While a certain level of NBT is inevitable, its extent, variation and justification need further scrutiny.

Patients now commonly survive conditions that once would have been fatal1. As modern medicine helps us push back against death, it is easy to congratulate ourselves on these successes and view outcomes for patients in the ICU in dichotomous terms: they either survive to ICU discharge or they don’t. However, we are increasingly aware of the complexity in outcomes for patients admitted to the ICU2. We also know that doctors and nurses working in ICUs believe that they sometimes provide unnecessary and futile treatments to patients3,4. In this edition, Henderson and Corke illustrate that the predominant default option for doctors in ICUs is to treat first and ask questions later5. Henderson’s paper raises an important concept, the use of the patient’s values in an intensive care doctor’s decision-making process to determine the intensity of treatment. They show that the provision of an advance directive, or “personal values report”, can alter the choice made. This is an important realisation. To put it in the language of a clinical trial, the primary outcome of treatment in an ICU is determined by the patient. Their wishes, and whether we align our treatments (both intensity and duration) with those wishes, will determine the success of the ICU admission. So this means we need two things: an understanding of the potential outcomes of ICU admission, not limited to survival, and the patient’s willingness to accept those outcomes (Figure 1). Back in 2003, Herridge et al published their landmark paper looking at the one year outcome for survivors of acute respiratory distress syndrome6. While the patients’ respiratory symptoms had largely improved, they still suffered from significant weakness and fatigue, with persistent limitations in their functional state at five years7. In this issue, Green et al present a review of functional outcomes for survivors of those who suffered an out-of-hospital cardiac arrest8. They showed that almost half of all survivors had cognitive impairment and mental health issues. The self-reported quality of life was predominantly positive, but approximately a fifth had impaired physical functioning. Worryingly, it appears that up to half of out-of-hospital cardiac arrest survivors did not return to work after hospital discharge, perhaps as a result of high levels of fatigue. Post-traumatic stress disorder was detected in a quarter of out-of-hospital cardiac arrest survivors, and it was even higher (50%) amongst the family and carers of the survivors. This highlights the large care-givers’ burden, likely to be in need of both practical and emotional support. Appropriately, Cuthbertson and colleagues have previously suggested that surviving a critical illness “should be treated as a lifetime diagnosis with associated excess mortality, morbidity and the requirement for ongoing health care support”9. This knowledge is both useful and problematic for the bedside ICU clinician. It is useful to forewarn patients and their families about the potential difficulties ahead of them. In addition, as critical care medicine continually improves, we are starting to think about mitigating the longer-term complications of critical illness. It is harder to answer the “how to” component of this issue. First of all, detection of post-ICU physical and mental impairments requires an accurate diagnostic tool and a mechanism for post-ICU follow-up to occur. As Green’s review shows, there are a large number of different scales in use, suggesting that there is not an optimal, one-size fits all scale, and that the accuracy and sensitivity may differ between them. Furthermore, ICU follow-up clinics are not common in Australia and the evidence from overseas surrounding their benefit is uncertain9. There is significant opportunity for further research into these two areas10. One way to start exploring how to alter long term outcomes for ICU patients is to better understand what outcomes really matter to them. Self reported quality of life is a thoughtprovoking outcome. Patients with chronic health conditions often rate their quality of life higher than people without similar diseases. People adapt to new health state, just as they adapt to other changes in their lives, that previously they would not have accepted11. This does not invalidate quality of life as an outcome measure, but illustrates the difficulty in picking and choosing the desired health outcomes. This brings us back to how vital it is to determine a patient’s wishes. It is concerning that Henderson et al found that “many doctors felt comfortable making these decisions without Editorial

Objective This study investigated the use of Modified Early Warning Scores (MEWS) as a tool for predicting chorioamnionitis (CA) following preterm, prolonged rupture of membranes (PPROM). Study design A retrospective observational study was undertaken at The Canberra Hospital, a tertiary referral center for high-risk pregnancies and neonatal intensive care, of all patients who underwent a PPROM with placental histology from September 2008 until January 2011. Patients and methods Seventy-five gestational-age-appropriate patients (20 weeks and 0 days to 36 weeks and 6 days) were identified with placental histology in association with PPROM from September 2008 to January 2011. After excluding patients younger than 18 years (one patient) and those with missing records (one patient), 73 patients remained, who were divided into two cohorts on the basis of their placental histology: 61 patients with CA (CA+) and 12 patients without CA (CA−). The Mann–Whitney U-test was used for group comparisons of demographics and MEWS, whereas comparisons of binomial proportions between two groups were performed using Fisher’s exact test. Significance was set at P values less than 0.05. Results Comparing CA+ and CA− PPROM patients, an MEWS of at least 2 was shown to have a sensitivity of 57.4% [95% confidence interval (CI): 44.1–70], specificity of 83.3% (95% CI: 51.6–97.4), and positive and negative likelihood ratios of 3.44 (95% CI: 0.95–12.43) and 0.51 (95% CI: 0.35–0.75), respectively. Conclusion The highest MEWS within 72 h before delivery is an additional aid in the diagnosis of CA following PPROM.

BACKGROUND:Outcomes for haematology/oncology patients have improved; however, determining their suitability for intensive care unit (ICU) admission remains challenging and controversial.AIM:Examine outcomes of patients admitted to an Australian tertiary hospital ICU and explore potential prognostic factors.METHODS:A retrospective review of patients with haematological and solid tumour malignancies non-electively admitted to The Canberra Hospital (TCH) ICU, between January 2008 and December 2012. Patient demographics, cancer details, reasons for ICU admission and Acute Physiologic and Chronic Health Evaluation (APACHE) II scores were collected, and survival rates calculated and correlated with potential prognostic factors.RESULTS:Of 205 patients, 113 (55%) had haematological malignancies, and 92 (45%) had solid tumours: 58% male and mean age 60.3 years (standard deviation (SD) 13.4). Eighty-two per cent of solid tumour patients had metastatic disease and 55% received palliative chemotherapy. Primary reasons for ICU admission included sepsis (59%), respiratory distress (37%) and hypotension/shock (18%). Mean APACHE II score was 20.1(SD 0.55); mean length of stay in ICU, 4 days (SD 5.2); ICU survival was 76% with 62% and 41% alive at 30 days and 6 months respectively. Overall 1-year survival was 36%. High APACHE II scores and ≥2 organs failing were significant risk factors for 30-day mortality.CONCLUSION:Short-term outcomes were similar to contemporary studies from a general tertiary hospital setting and better than historical data. Sixty-two per cent of patients were alive 30 days post-ICU admission, with a significant minority alive at 12 months, confirming some patients achieved worthwhile outcomes. Further research is needed to ensure appropriate patient selection and to explore quality of life post ICU.

PURPOSE:Recently there has been increased interest in early mobilization of critically ill patients. Proposed benefits include improvements in respiratory function, muscle wasting, intensive care unit (ICU), and hospital length of stay. We studied the frequency of early mobilization in our intensive care unit in order to identify barriers to early mobilization.METHODS:A 4-week prospective audit of 106 patients admitted to a mixed medical-surgical tertiary ICU (mean age 60 ± 20 years, mean APACHE II score 14.7 ± 7.8) was performed. Outcome measures included number of patient days mobilized, type of mobilization, adverse events, and reasons for inability to mobilize.RESULTS:Patients were mobilized on 176 (54%) of 327 patient days. Adverse events occurred in 2 of 176 mobilization episodes (1.1%). In 71 (47%) of the 151 patient days where mobilization did not occur, potentially avoidable factors were identified, including vascular access devices sited in the femoral region, timing of procedures and agitation or reduced level of consciousness.CONCLUSIONS:Critically ill patients can be safely mobilized for much of their ICU stay. Interventions that may allow more patients to mobilize include: changing the site of vascular catheters, careful scheduling of procedures, and improved sedation management.

My early years were spent living behind my parents' grocery shop. It was in the days before large multi-nationals. It was even before customer service had a name. In those days customer service was a way of living. Without the customer there was no income. Without an income I knew my life would be less secure. The customers were our community. Many of them formed how I now think and act.

Aim: To determine whether the introduction of a multi-faceted intervention (newly designed ward observation chart, a track and trigger system and an associated education program, COMPASS (R)) to detect clinical deterioration in patients would decrease the rate of predefined adverse outcomes.Methods: A prospective, controlled before-and-after intervention of trial was conducted in all consecutive adult patients admitted to four medical and surgical wards during a 4 month period, 1157 and 985, respectively. A sub-group of patients underwent vital sign and medical review analysis pre-intervention (427) and post-intervention (320). The outcome measures included: number of unplanned admissions to the intensive care unit (ICU), Medical Emergency Team (MET) reviews and unexpected hospital deaths, vital sign documentation frequency and incidence of a medical review following clinical deterioration. This study is registered, ACTRN12609000808246.Results: Reductions were seen in unplanned admissions to ICU (21/1157 [1.8%] vs. 5/985[0.5%], p = 0.006) and unexpected hospital deaths (11/1157 [1.0%] vs. 2/985 [0.2%], p = 0.03) during the intervention period. Medical reviews for patients with significant clinical instability (58/133 [43.6%] vs. 55/79 [69.6%] p < 0.001) and number of patients receiving a MET review increased (25/1157 [2.2%] vs. 38/985 [3.9%] p = 0.03) during the intervention period. Mean daily frequency of documentation of all vital signs increased during the intervention period (3.4 [SE 0.22] vs. 4.5 [ SE 0.17], p = 0.001).Conclusion: The introduction of a multi-faceted intervention to detect clinical deterioration may benefit patients through increased monitoring of vital signs and the triggering of a medical review following an episode of clinical instability. Crown Copyright (C) 2010 Published by Elsevier Ireland Ltd. All rights reserved.

Objective To describe the epidemiology of 2009 A/H1N1 influenza in critically ill pregnant women.Design Population based cohort study.Setting All intensive care units in Australia and New Zealand.Participants All women with 2009 H1N1 influenza who were pregnant or recently post partum and admitted to an intensive care unit in Australia or New Zealand between 1 June and 31 August 2009.Main outcome measures Maternal and neonatal mortality and morbidity.Results 64 pregnant or postpartum women admitted to an intensive care unit had confirmed 2009 H1N1 influenza. Compared with non-pregnant women of childbearing age, pregnant or postpartum women with 2009 H1N1 influenza were at increased risk of admission to an intensive care unit (relative risk 7.4, 95% confidence interval 5.5 to 10.0). This risk was 13-fold greater (13.2, 9.6 to 18.3) for women at 20 or more weeks' gestation. At the time of admission to an intensive care unit, 22 women (34%) were post partum and two had miscarried. 14 women (22%) gave birth during their stay in intensive care and 26 (41%) were discharged from an intensive care unit with ongoing pregnancy. All subsequently delivered. 44 women (69%) were mechanically ventilated. Of these, nine (14%) were treated with extracorporeal membrane oxygenation. Seven women (11%) died. Of 60 births after 20 weeks' gestation, four were stillbirths and three were infant deaths. 22 (39%) of the liveborn babies were preterm and 32 (57%) were admitted to a neonatal intensive care unit. Of 20 babies tested, two were positive for the 2009 H1N1 virus.Conclusions Pregnancy is a risk factor for critical illness related to 2009 H1N1 influenza, which causes maternal and neonatal morbidity and mortality.