The relationship between nursing skill mix and severity of illness of patients admitted in Australian and New Zealand intensive care units

BackgroundCritically ill patients in the intensive care environment require an appropriate nursing workforce to improve quality of care and patient outcomes. However, limited information exists as to the relationship between severity of illness and nursing skill mix in the intensive care.ObjectiveThe aim of this study was to describe the variation in nursing skill mix across different hospital types and to determine if this was associated with severity of illness of critically ill patients admitted to adult intensive care units (ICUs) in Australia and New Zealand.Design & SettingA retrospective cohort study using the Australia and New Zealand Intensive Care Society Adult Patient Database (to provide information on patient demographics, severity of illness, and outcome) and the Critical Care Resources Registry (to provide information on annual nursing staffing levels and hospital type) from July 2014 to June 2020. Four hospital types (metropolitan, private, rural/regional, and tertiary) and three patient groups (elective surgical, emergency surgical, and medical) were examined.Main outcome measureThe main outcome measure was the proportion of critical care specialist registered nurses (RNs) expressed as a percentage of the full-time equivalent (FTE) of total RNs working within each ICU each year, as reported annually to the Critical Care Resources Registry.ResultsData were examined for 184 ICUs in Australia and New Zealand. During the 6-year study period, 770 747 patients were admitted to these ICUs. Across Australia and New Zealand, the median percentage of registered nursing FTE with a critical care qualification for each ICU (n = 184) was 59.1% (interquartile range [IQR] = 48.9–71.6). The percentage FTE of critical care specialist RNs was highest in private [63.7% (IQR = 52.6–78.2)] and tertiary ICUs [58.1% (IQR = 51.2–70.2)], followed by metropolitan ICUs [56.0% (IQR = 44.5–68.9)] with the lowest in rural/regional hospitals [55.9% (IQR = 44.9–70.0)]. In ICUs with higher percentage FTE of critical care specialist RNs, patients had higher severity of illness, most notably in tertiary and private ICUs. This relationship was persistent across all hospital types when examining subgroups of emergency surgical and medical patients and in multivariable analysis after adjusting for the type of hospital and relative percentage of each diagnostic group.ConclusionsIn Australian and New Zealand ICUs, the highest acuity patients are cared for by nursing teams with the highest percentage FTE of critical care specialist RNs. The Australian and New Zealand healthcare system has a critical care nursing workforce which scales to meet the acuity of ICU patients across Australia and New Zealand.     

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

ObjectiveThe objective of this study was to describe family visitation policies, facilities, and support in Australia and New Zealand (ANZ) intensive care units (ICUs).MethodsA 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 participantsThis study included all Australian and New Zealand ICUs reporting to CCR in 2018.Main outcome measuresThe 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.FindingsFifty-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.ConclusionsIn 2018, the majority of ANZ ICUs reported liberal visiting policies, with substantial facilities and family support.     

Bullying,discrimination, and sexual harassment among intensive care unit nurses in Australia and New Zealand: An online survey

BackgroundBullying, discrimination, and sexual harassment are significant problems within healthcare organisations but are often under-reported. Consequences of these behaviours within a healthcare setting are wide ranging, affecting workplace environments, personal well-being, and patient care and leading to increased staff turnover and quality of patient care and outcomes. Whilst there has been some work undertaken in the general nursing workforce, there is a dearth of evidence regarding the extent and impact of these behaviours on the nursing workforce in intensive care units (ICUs) in Australia and New Zealand.ObjectiveWe aimed to determine self-reported occurrences of bullying, discrimination, and sexual harassment amongst ICU nurses in Australia and New Zealand.MethodsA prospective, cross-sectional, online survey of ICU nurses in Australia and New Zealand was undertaken in May–June 2021, distributed through formal colleges, societies, and social media. Questions included demographics and three separate sections addressing bullying, sexual harassment, and discrimination.ResultsIn 679 survey responses, the overall reported occurrences of bullying, discrimination, and sexual harassment in the last 12 months were 57.1%, 32.6%, and 1.9%, respectively. Perpetrators of bullying were predominantly nurses (59.6%, with 57.9% being ICU nurses); perpetrators of discrimination were nurses (51.7%, with 49.3% being ICU nurses); and perpetrators of sexual harassment were patients (34.6%). Respondents most commonly (66%) did not report these behaviours as they did not feel confident that the issue would be resolved or addressed.ConclusionsDetermining the true extent of bullying, discrimination, and sexual harassment behaviours within the ICU nursing community in Australia and New Zealand is difficult; however, it is clear a problem exists. These behaviours require recognition, reporting, and an effective resolution, rather than normalisation within healthcare professions and workplace settings in order to support and retain ICU nursing staff.     

Thromboprophylaxis for intensive care patients in Australia and New Zealand: a brief survey report

PURPOSE: Internationally, there is practice variation concerning optimal thromboprophylaxis for patients in the intensive care unit (ICU). The current practice in Australia and New Zealand is unknown. METHOD: We conducted a self-administered e-mail survey of 22 Australian and New Zealand ICUs expressing interest in participating in a proposed international randomized trial (PROphylaxis for ThromboEmbolism in Critical Care Trial). RESULTS: Our response rate was 95.4% (95% CI, 77%-100%). Of participating ICUs, 90.5% (95% CI, 70%-99%) used subcutaneous unfractionated heparin for routine thromboprophylaxis in ICU patients. Low-molecular-weight heparin was reserved for specific high-risk patients in many units. CONCLUSION: Routine thromboprophylaxis for ICU patients in Australia and New Zealand is similar to Canada but different to France. Optimal thromboprophylaxis for ICU patients is currently unclear in the absence of randomized trial data.     

Physiotherapy services in intensive care. A workforce survey of Australia and New Zealand

BackgroundIn Australia and New Zealand, there are currently no recommendations to guide staffing levels for intensive care unit (ICU) physiotherapy services, and there is limited information about the current services provided.ObjectivesThe objective of this study was to document the profile of intensive care physiotherapy services currently offered in Australia and New Zealand.MethodsA binational survey was distributed to physiotherapists. The survey sought information on staffing and service profiles for weekday, weekend, and after-hour services including on-call and evening shifts.ResultsEighty-six sites completed the survey, with responses primarily from Level 3 (47/86, 55%) and public ICUs (74/86, 86%). For weekday services, the ratio of full-time equivalent physiotherapy staff allocated per bed was similar between all intensive care levels (0.11 [0.08–0.15], p = 0.421). Thirty respondents (35%) were satisfied with their staffing and reported higher levels of physiotherapy staff per bed (0.15 [0.1–0.2], p < 0.001). Most sites reported lower levels of staffing for weekend services (76/86, 88%), and many physiotherapists indicated that they were not satisfied with this service (55/86, 64%). Most Level 2, Level 3, and paediatric ICUs had a designated senior physiotherapist, with similar levels of senior physiotherapy staff allocated per bed between all ICU levels (0.05 [0.03–0.08], p = 0.844). Few sites reported dedicated staff attributed to intensive care education, research, tracheostomy service, or outreach roles. On-call physiotherapy services were available in 49 of 86 (57%) hospitals surveyed; however, utilisation of the service by ICUs was mainly reported to be less than once per month (19/49, 39%).ConclusionsPhysiotherapy staffing ratios were similar across different ICU levels. While weekend services are available for most ICUs, staffing levels are reduced. Higher staffing ratios were associated with higher levels of satisfaction to complete professional roles and responsibilities.     

Glycaemic control in Australia and New Zealand before and after the NICE-SUGAR trial: a translational study

Introduction

There is no information on the uptake of Intensive Insulin Therapy (IIT) before the Normoglycemia in Intensive Care Evaluation and Surviving Using Glucose Algorithm Regulation (NICE-SUGAR) trial in Australia and New Zealand (ANZ) and on the bi-national response to the trial, yet such data would provide important information on the evolution of ANZ practice in this field. We aimed to study ANZ glycaemic control before and after the publication of the results of the NICE-SUGAR trial.

Methods

We analysed glucose control in critically ill patients across Australia and New Zealand during a two-year period before and after the publication of the NICE-SUGAR study. We used the mean first day glucose (Glu₁) (a validated surrogate of ICU glucose control) to define practice. The implementation of an IIT protocol was presumed if the median of Glu₁ measurements was <6.44 mmol/L for a given ICU. Hypoglycaemia was categorised as severe (glucose ≤2.2 mmol/L) or moderate (glucose ≤3.9 mmol/L).

Results

We studied 49 ICUs and 176,505 patients. No ICU practiced IIT before or after NICE-SUGAR. Overall, Glu₁ increased from 7.96 (2.95) mmol/L to 8.03 (2.92) mmol/L (P <0.0001) after NICE-SUGAR. Similar increases were noted in all patient subgroups studied (surgical, medical, insulin dependent diabetes mellitus, ICU stay >48/<48 hours). The rate of severe and moderate hypoglycaemia before and after NICE-SUGAR study were 0.59% vs. 0.55% (P =0.33) and 6.62% vs. 5.68% (P <0.0001), respectively. Both crude and adjusted mortalities declined over the study period.

Conclusions

IIT had not been adopted in ANZ before the NICE-SUGAR study and glycaemic control corresponded to that delivered in the control arm of NICE-SUGAR trial. There were only minor changes in practice after the trial toward looser glycaemic control. The rate of moderate hypoglycaemia and mortality decreased along with such changes.     

Characterizing critical care physician staffing in rural America: A description of Iowa intensive care unit staffing

Purpose

This study aimed to characterize intensive care unit (ICU) physician staffing patterns in a predominantly rural state.

Materials and Methods

A prospective telephone survey of ICU nurse managers in all Iowa hospitals with an ICU was conducted.

Results

Of 122 Iowa hospitals, 64 ICUs in 58 (48%) hospitals were identified, and 46 (72%) responded to the survey. Most ICUs (96%) used an open admission model and cared for undifferentiated medical and surgical patients (88%), and only 27% of open ICUs required critical care or pulmonary consultation for admitted patients. Most (59%) Iowa ICUs had a critical care physician or pulmonologist available, and high-intensity staffing was practiced in 30% of ICUs. Most physicians identified as practicing critical care (63%) were not board certified in critical care. Critical care physicians were available in a minority of hospitals routinely for inpatient intubation and cardiac arrest management (29% and 10%, respectively), and emergency physicians and other practitioners commonly responded to emergencies throughout the hospital.

Conclusions

Many Iowa hospitals have ICUs, and staffing patterns in Iowa ICUs mirror closely national staffing practices. Most ICUs are multispecialty, open ICUs in community hospitals. These factors should inform training and resource allocation for intensivists in rural states.     

Nursing workforce deployment and intensive care unit strain during the COVID-19 pandemic in Victoria,Australia

BackgroundThe COVID-19 pandemic demanded intensive care units (ICUs) globally to expand to meet increasing patient numbers requiring critical care. Critical care nurses were a finite resource in this challenge to meet growing patient numbers, necessitating redeployment of nursing staff to work in ICUs.ObjectiveOur aim was to describe the extent and manner by which the increased demand for ICU care during the COVID-19 pandemic was met by ICU nursing workforce expansion in the late 2021 and early 2022 in Victoria, Australia.MethodsThis is a retrospective cohort study of Victorian ICUs who contributed nursing data to the Critical Health Information System from 1 December 2021 to 11 April 2022. Bedside nursing workforce data, in categories as defined by Safer Care Victoria’s pandemic response guidelines, were analysed. The primary outcome was ‘insufficient ICU skill mix’—whenever a site had more patients needing 1:1 critical care nursing care than the mean daily number of experienced critical care nursing staff.ResultsOverall, data from 24 of the 47 Victorian ICUs were eligible for analysis. Insufficient ICU skill mix occurred on 10.3% (280/2725) days at 66.7% (16/24) of ICUs, most commonly during the peak phase from December to mid-February. The insufficient ICU skill mix was more likely to occur when there were more additional ICU beds open over the ‘business-as-usual’ number. Counterfactual analysis suggested that had there been no redeployment of staff to the ICU, reduced nursing ratios, with inability to provide 1:1 care, would have occurred on 15.2% (415/2725) days at 91.7% (22/24) ICUs.ConclusionThe redeployment of nurses into the ICU was necessary. However, despite this, at times, some ICUs had insufficient staff to cope with the number and acuity of patients. Further research is needed to examine the impact of ICU nursing models of care on patient outcomes and on nurse outcomes.     

A national survey of intensive care follow-up clinics in Australia

BackgroundIntensive care follow-up clinics (ICFCs) have been implemented internationally with the aim to address the growing number of patients living with sequalae of critical illness and intensive care. However, data on Australian intensive care follow-up practice are rare.ObjectivesThe primary objective was to determine the proportion of Australian intensive care units (ICUs) that offer a dedicated ICFC to ICU survivors, with the intention of improving long-term outcomes of critical illness. Secondary objectives were to identify models of ICU follow-up and barriers to the implementation of ICFCs.MethodsA custom-designed, pilot-tested 12-question online survey was sent to the nurse unit managers and medical directors of all 167 Australian ICUs listed in the database of the Australian and New Zealand Intensive Care Society. Outcome measures included proportion of ICUs offering ICFCs, details on types of follow-up services with staffing, funding source, and reasons for not providing ICU follow-up.ResultsOne hundred seven of the 167 ICUs contacted responded to the survey. Of these, two (2%) operated a dedicated ICFC. Both ICFCs were nursing-led, with one receiving dedicated funding and the other being unfunded. Three units (3%) conducted routine outpatient follow-up by telephone; one of these services was doctor-led, and two were nurse-led. Four units (4%) were performing outpatient follow-up as part of research studies only. Among the units not operating an ICFC, the main reason given for not doing so were financial constraints (58%), followed by lack of clinical need (19%) and perceived lack of evidence (11%).ConclusionIn Australia, only two ICUs operated an ICFC. Only one outpatient follow-up service received dedicated funding, and financial constraints were the main reason given for units not offering outpatient follow-up services.     

Management of blood glucose in the critically ill in Australia and New Zealand: a practice survey and inception cohort study

Objective To document current management of blood glucose in Australian and New Zealand intensive care units (ICUs) and to investigate the association between insulin administration, blood glucose concentration and hospital outcome.Design and setting Practice survey and inception cohort study in closed multi-disciplinary ICUs in Australia and New Zealand.Patients Twenty-nine ICU directors and 939 consecutive admissions to 29 ICUs during a 2-week period.Measurement and results Data collected included unit approaches to blood glucose management, patient characteristics, blood glucose concentrations, insulin administration and patient outcomes. Ten percent of the ICU directors reported using an intensive insulin regimen in all their patients. In 861 patients (91.7%) blood glucose concentration was greater than 6.1 mmol/l, 287 (31.1%) received insulin, and the median blood glucose concentration triggering insulin administration was 11.5 (IQR 9.4–14) mmol/l. Univariate analysis demonstrated that non-survivors had a higher maximum daily blood glucose concentration (12 mmol/l, 9.4–14.8, vs. 9.5, 7.6–12.2) and were more likely to receive insulin (47% vs. 28%). Multiple logistic regression analysis showed age (OR per 5-year decrease 0.93, 95% CI 0.87–1.00) and APACHE II (OR per point decrease 0.87, 95% CI 0.84–0.90) to be independently associated with hospital mortality. After controlling for age and APACHE II both daily highest blood glucose (OR 0.95, 95% CI 0.90–1.00) and administration of insulin (OR 0.62, 95% CI 0.39–1.00) were independently associated when added to the model alone; neither was independently associated when they were simultaneously included in the model.Conclusion Few Australian and New Zealand ICUs have adopted intensive insulin therapy. In this study, insulin administration and highest daily blood glucose concentration could not be separated in their association with hospital mortality.Electronic supplementary material The electronic reference of this article is . The online full-text version of this article includes electronic supplementary material. This material is available to authorised users and can be accessed by means of the ESM button beneath the abstract or in the structured full-text article. To cite or link to this article you can use the above reference.     

Delirium in intensive care: A stepped-wedge cluster randomised controlled trial for a nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to the intensive care unit (protocol)

BackgroundDelirium is an acute disorder of attention and cognition with the highest rates among adults receiving intensive care. An acute episode of delirium is associated with morbidity and mortality, as well as a significant psychological sequela. Importantly, an increasing body of evidence supports the benefit of nonpharmacological, nurse-led interventions to reduce the incidence and duration of delirium among adults cared for in the intensive care unit (ICU).ObjectivesThis study will evaluate the impact of a nursing-led delirium prevention protocol that is aimed at reducing the incidence and duration of delirium among adults admitted to the ICU. The delirium prevention nursing protocol specifically targets risk factors for delirium.Study planA stepped-wedge cluster randomised controlled trial approach will be used to assess the effectiveness of the nurse-led intervention, in four adult ICUs across the South Western Sydney Local Health District (SWS-LHD), over a 12-month period. The primary outcomes of interest are (i) the incidence of delirium before and after the implementation of the nurse-led intervention and (ii) the number of delirium-free days during an ICU stay, before and after the implementation of the nurse-led intervention.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTR): (ACTRN12618000411246p)     

Staff perceptions of family access and visitation policies in Australian and New Zealand intensive care units: The WELCOME-ICU survey

BackgroundFamily-centred critical care recognises the impact of a loved one's critical illness on his relatives. Open visiting is a strategy to improve family satisfaction and psychological outcomes by permitting unrestricted or less restricted access to visit their family member in the intensive care unit (ICU). However, increased family presence may result in increased workload and a risk of burnout for ICU staff.ObjectivesThe objective of this study was to evaluate ICU staff perceptions regarding visiting hours and family access in Australian and New Zealand ICUs. Secondary outcomes included an evaluation of current visiting policies, witnessed events in ICUs, and barriers to implementing open visiting policies.DesignA web-based survey open to all healthcare workers in Australia and New Zealand ICUs was distributed through local, state-based, and national critical care networks. Open visiting was defined as ICUs open for visiting >14 h per day.Main resultsWe received 1255 valid responses. Most respondents were nurses (n = 930, 74.1%) with a median critical care experience of 10 y. Most worked in open visiting ICUs (n = 749, 59.7%). Reported visiting hours varied greatly with a median of 20 h per day (interquartile range: 10–24 h). Open visiting was perceived as beneficial for the relatives, but less so for patients and staff (relatives: n = 845, 67.3%, patients: n = 561, 44.7%, staff: n = 257, 20.5%, p < 0.0001). Respondents from closed visiting units and nurses identified more risks from open visiting than other professional groups. Generally, staff preferred not to change from their current practice.ConclusionWe report that staff perceived open visiting as beneficial for relatives, but also identified risks to themselves, including increased workload, a risk of burnout, and a risk of occupational violence. Reluctance to change highlights the importance of addressing staff perceptions when implementing an open visiting policy.     

The intensivist's assessment of gastrointestinal function: A pilot study

Gastrointestinal dysfunction/failure (GDF) is a common cause of concern in critically ill patients. Although the gut plays an important role in the genesis of organ failure, its exclusion from organ severity scoring systems has made it challenging for intensivists to score it sufficiently at the bedside. We aimed to survey intensive care specialists about their perceptions, attitudes, and approaches towards the assessment of the gut in Australia and New Zealand intensive care units (ICUs). An electronic (online) questionnaire was used to survey intensive care specialists from the Australia and New Zealand Intensive Care Society (ANZICS). The survey comprised 10 questions focused on four key areas: (i) the extent of the problem with GDF in ICUs, (ii) the use and reliability of the current gut scoring tools, (iii) personal approaches and practices associated with GDF assessment, and (4) potential value of a novel GDF scoring system and its incorporation into an organ severity score. Our results showed that GDF was a significant concern amongst ICUs in Australia and New Zealand intensivists (84%; 66/79), with a small number of participants (14%; 3/79) using a gut scoring tool in their ICUs. Despite this, we have no established objective scoring tool for its assessment. The survey highlighted the need for developing a novel scoring tool to assess the gut was considered important amongst majority of the intensivists (92%; 72/78), which would prove useful in clinical practice and potentially lead to incorporation into an organ severity score in the future.     

Staff knowledge,attitudes and practices regarding glycaemic management in adult intensive care units: A national survey

Background

Hyperglycaemia is common in critically ill adult patients. Many studies have identified the content, methods, and effects of glycaemic control but have not explored the effects of knowledge, attitudes, and practices (KAP) on glycaemic control in critically ill adults. Various factors also influence the KAP of intensive care unit (ICU) staff.

Aims

To assess KAP regarding glucose management for critically ill adults among nurses and medical professionals and identify the factors that influence their KAP in ICUs.

Methods

A multicentre cross-sectional survey.

Results

In total, 403/459 (response rate: 87.8%) participants from ICUs in nine tertiary hospitals in China participated in this study, 82.4% of whom were female and 93.4% of whom were nurses. The mean work experience was 8.88 years, and the mean critical care experience was 6.59 years. The scoring rate for the three dimensions of knowledge, attitudes, and practices were 82.35%, 87.69%, and 76%, respectively. We did not find any other factors affecting the KAP scores except for the level of knowledge awareness (p < 0.001), awareness of the importance (p < 0.001), and training for glucose control (p = 0.004).

Conclusion

ICU staff KAP regarding glycaemic control in critically ill adults among ICU professionals were acceptable in China. However, ICU professionals' current knowledge regarding nutrition, glucose variability, and skills related to glucose management could be improved.

Relevance to Clinical Practice

ICU educators should provide more skills-related training for healthcare professionals in the glycaemic management of critically ill adults. Moreover, the process of managing blood glucose in adult ICU patients is a collaborative, multidisciplinary team effort, with monitoring and feedback required during implementation.     

Emergency physician-based intensive care unit for critically ill patients visiting emergency department

BackgroundTo provide a prompt and optimal intensive care to critically ill patients visiting our emergency department (ED), we set up and ran a specific type of emergency intensive care unit (EICU) managed by emergency physician (EP) intensivists. We investigated whether this EICU reduced the time interval from ED arrival to ICU transfer (ED-ICU interval) without altering mortality.MethodsThis was a retrospective study conducted in a tertiary referral hospital. We collected data from ED patients who were admitted to the EICU (EICU group) and other ICUs including medical, surgical, and cardiopulmonary ICUs (other ICUs group), from August 2014 to July 2017. We compared these two groups with respect to demographic findings, including the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, ED-ICU interval, ICU mortality, and hospital mortality.ResultsAmong the 3440 critically ill patients who visited ED, 1815 (52.8%) were admitted to the EICU during the study period. The ED-ICU interval for the EICU group was significantly shorter than that for the other ICUs group by 27.5% (5.0 ± 4.9 vs. 6.9 ± 5.4 h, p < 0.001). In multivariable analysis, the ICU mortality (odds ratio = 1.062, 95% confidence interval 0.862–1.308, p = 0.571) and hospital mortality (odds ratio = 1.093, 95% confidence interval 0.892–1.338, p = 0.391) of the EICU group were not inferior to those of the other ICUs group.ConclusionsThe EICU run by EP intensivists reduced the time interval from ED arrival to ICU transfer without altering hospital mortality.     

Personal protective equipment preparedness in Asia-Pacific intensive care units during the coronavirus disease 2019 pandemic: A multinational survey

BackgroundThere has been a surge in coronavirus disease 2019 admissions to intensive care units (ICUs) in Asia-Pacific countries. Because ICU healthcare workers are exposed to aerosol-generating procedures, ensuring optimal personal protective equipment (PPE) preparedness is important.ObjectiveThe aim of the study was to evaluate PPE preparedness across ICUs in six Asia-Pacific countries during the initial phase of the coronavirus disease 2019 pandemic, which is defined by the World Health Organization as guideline adherence, training healthcare workers, procuring stocks, and responding appropriately to suspected cases.MethodsA cross-sectional Web-based survey was circulated to 633 level II/III ICUs of Australia, New Zealand (NZ), Singapore, Hong Kong (HK), India, and the Philippines.FindingsTwo hundred sixty-three intensivists responded, representing 231 individual ICUs eligible for analysis. Response rates were 68–100% in all countries except India, where it was 24%. Ninety-seven percent of ICUs either conformed to or exceeded World Health Organization recommendations for PPE practice. Fifty-nine percent ICUs used airborne precautions irrespective of aerosol generation procedures. There were variations in negative-pressure room use (highest in HK/Singapore), training (best in NZ), and PPE stock awareness (best in HK/Singapore/NZ). High-flow nasal oxygenation and noninvasive ventilation were not options in most HK (66.7% and 83.3%, respectively) and Singapore ICUs (50% and 80%, respectively), but were considered in other countries to a greater extent. Thirty-eight percent ICUs reported not having specialised airway teams. Showering and “buddy systems” were underused. Clinical waste disposal training was suboptimal (38%).ConclusionsMany ICUs in the Asia-Pacific reported suboptimal PPE preparedness in several domains, particularly related to PPE training, practice, and stock awareness, which requires remediation. Adoption of low-cost approaches such as buddy systems should be encouraged. The complete avoidance of high-flow nasal oxygenation reported by several intensivists needs reconsideration. Consideration must be given to standardise PPE guidelines to minimise practice variations. Urgent research to evaluate PPE preparedness and severe acute respiratory syndrome coronavirus 2 transmission is required.     

Are point-of-care measurements of glycated haemoglobin accurate in the critically ill?

IntroductionCritically ill patients with type 2 diabetes mellitus (T2DM) and chronic hyperglycaemia may benefit from a more liberal approach to glucose control than patients with previously normal glucose tolerance. It may therefore be useful to rapidly determine HbA1c concentrations. Point-of-care (POC) analysers offer rapid results but may be less accurate than laboratory analysis.Aim(s)The aim of this study was to determine agreement between POC and laboratory HbA1c testing in critically ill patients with T2DM.MethodsCritically ill patients with T2DM had concurrent laboratory, capillary-, and arterial-POC HbA1c measurements performed. Data are presented as mean (standard deviation) or median [interquartile range]. Measurement agreement was assessed by Lin's concordance correlation coefficient, Bland–Altman 95% limits of agreement, and classification by Cohen's kappa statistic.ResultsHbA1c analysis was performed for 26 patients. The time to obtain a result from POC analysis took a median of 9 [[7], [10]] minutes. Laboratory analysis took a median of 328 [257, 522] minutes from the time of test request to the time of report. Lin's correlation coefficient showed almost perfect agreement (0.99%) for arterial- vs capillary-POC and both POC methods vs arterial laboratory analysis. Bland–Altman plots showed a mean difference of 2.0 (3.7) with 95% limits of agreement of ?5.4 to 9.3 for capillary vs laboratory, 1.6 (3.4) and ?5.1 to 8.4 for arterial vs laboratory, and ?0.137 (2.6) and ?5.2 to 4.9 for capillary vs arterial. Patient classification as having inadequately controlled diabetes (>53 mmol/mol) showed 100% agreement across all tests.ConclusionsHbA1c values can be accurately and rapidly obtained using POC testing in the critically ill.     

Capacity of intensive care units in Ghana

PurposeTo document the equipment, resource and bed capacity of Intensive Care Units (ICUs) in the Republic of Ghana.Materials and methodsCross-sectional observational study of all operating ICUs in Ghana. Sixteen operating ICUs in 9 hospitals were identified and surveyed (13 adult and 3 pediatric ICUs).ResultsThere were a total of 113 adult and 36 pediatric ICU beds for a population of 30 million, (0.5 ICU beds per 100,000 people). The median number of staffed ICU beds and ventilators were 5 (IQR 4–6), and 4 (IQR 3–5) respectively. There were 2 pediatric and 6 adult intensivists practicing in the country. About half of the ICUs (56%) were staffed solely by non-intensivist providers. While there is adequate nursing support and availability of essential critical care medications, the current financing model for critical care delivery creates a significant barrier for most patients.ConclusionGhana has a significant shortage of critical care beds that are inequitably distributed across the country and a shortfall of intensivists to staff ICUs. A holistic approach that focuses on the key bottlenecks to quality improvement would be required to improve the capacity and quality of critical care delivery.     

Development and implementation of a high-quality clinical database: the Australian and New Zealand Intensive Care Society Adult Patient Database

OBJECTIVE: To describe the development of a binational intensive care database. SETTING: One hundred thirty-eight intensive care units (ICUs) in Australia and New Zealand. METHODS: A structure was developed to enable ICUs to submit data for central and local analysis. Reports were developed to allow comparison with similar ICU types and against published mortality prediction models. The database was evaluated according to (a) the criteria of the Directory of Clinical Databases (DoCDat) and (b) a proposed framework for data quality assurance in medical registries. RESULTS: Between January 1987 and December 2003, 444,147 data sets were collected from 121 (72.5%) of 167 Australian and 10 (37.0%) of 27 New Zealand ICUs. Data sets from more than 60000 ICU admissions were submitted in 2003. Overall hospital mortality was 14.5%. The mean quality level achieved according to DoCDat criteria was high as was performance against a proposed framework for data quality. The provision of no-cost software has been vitally important to the success of the database. CONCLUSION: A high-quality ICU database has successfully been implemented in Australia and New Zealand and is now used as a routine quality assurance and peer review tool. Similar developments may be both possible and desirable in other countries.