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Barry Dixon,1– 3 Jessica M Sharkey,1 Elliot J Teo,1,2 Sally A Grace,1 Jacqui S Savage,1 Andrew Udy,4 Paul Smith,5,6 Jack Hellerstedt,1 John D Santamaria2 1Cyban Pty Ltd, Melbourne, VIC, Australia; 2Department of Critical Care Medicine, St Vincent’s Hospital, Melbourne, Australia; 3Department of Medicine, University of Melbourne, Melbourne, Vic, Australia; 4Department of Critical Care Medicine, The Alfred Hospital, Melbourne, Australia; 5Department of Neurosurgery, St Vincent’s Hospital, Melbourne, Australia; 6University of Melbourne Medical School, Melbourne, Vic, AustraliaCorrespondence: Barry Dixon, Department of Critical Care Medicine, St Vincent’s Hospital (Melbourne), 41 Victoria Parade, Fitzroy, VIC, 3065, Australia, Tel +61 3 9231 4425, Email barry.dixon@svha.org.auBackground: Intracranial pressure (ICP) monitoring requires placing a hole in the skull through which an invasive pressure monitor is inserted into the brain. This approach has risks for the patient and is expensive. We have developed a non-invasive brain pulse monitor that uses red light to detect a photoplethysmographic (PPG) signal arising from the blood vessels on the brain’s cortical surface. The brain PPG and the invasive ICP waveform share morphological features which may allow measurement of the intracranial pressure.Methods: We enrolled critically ill patients with an acute brain injury with invasive ICP monitoring to assess the new monitor. A total of 24 simultaneous invasive ICP and brain pulse monitor PPG measurements were undertaken in 12 patients over a range of ICP levels.Results: The waveform morphologies were similar for the invasive ICP and brain pulse monitor PPG approach. Both methods demonstrated a progressive increase in the amplitude of P2 relative to P1 with increasing ICP levels. An automated algorithm was developed to assess the PPG morphological features in relation to the ICP level. A correlation was demonstrated between the brain pulse waveform morphology and ICP levels, R2=0.66, P < 0.001.Conclusion: The brain pulse monitor’s PPG waveform demonstrated morphological features were similar to the invasive ICP waveform over a range of ICP levels, these features may provide a method to measure ICP levels.Trial Registration: ACTRN12620000828921.Keywords: intracranial pressure, acute brain injury, monitoring, non-invasive, photoplethysmography

BACKGROUND: The national hospital-acquired complications (HAC) system has been promoted as a method to identify health care errors that may be mitigated by clinical interventions. OBJECTIVES: To quantify the rate of HAC in multiday stay adults admitted to major hospitals. DESIGN: Retrospective observational analysis of 5-year (July 2014 – June 2019) administrative dataset abstracted from medical records. SETTING: All 47 hospitals with on-site intensive care units (ICUs) in the State of Victoria. PARTICIPANTS: All adults (aged ≥ 18 years) stratified into planned or unplanned, surgical or medical, ICU or other ward, and by hospital peer group (tertiary referral, metropolitan, regional). MAIN OUTCOME MEASURES: HAC rates in ICU compared with ward, and mixed-effects regression estimates of the association between HAC and i) risk of clinical deterioration, and ii) admission hospital site (intraclass correlation coefficient [ICC] > 0.3). RESULTS: 211 120 adult ICU separations with mean hospital mortality of 7.3% (95% CI, 7.2–7.4%) reported 110 132 (42.6%) HAC events (commonly, delirium, infection, arrhythmia and respiratory failure) in 62 945 records (29.8%). Higher HAC rates were reported in elective (cardiac [50.3%] and non-cardiac [40.6%]) surgical subgroups compared with emergency medical subgroup (23.9%), and in tertiary (35.4%) compared with non-tertiary (22.7%) hospitals. HAC was strongly associated with on-admission patient characteristics (P < 0.001), but was weakly associated with hospital site (ICC, 0.08; 95% CI, 0.05–0.11). CONCLUSIONS: Critically ill patients have a high burden of HAC events, which appear to be associated with patient admission characteristics. HAC may an indicator of hospital admission complexity rather than hospital-acquired complications.

Background Frailty is common among acute hospital patients and might adversely affect recovery from inpatient cardiac arrest. Aim To assess the relationship between hospital admission characteristics, including frailty, and discharge outcome after in-hospital cardiac arrest. Methods Prospectively collected data were retrospectively analysed for all separations from a tertiary hospital during 2008-2017 that involved rapid response team attendance for cardiac arrest. Hospital Frailty Risk Score (HFRS) and Charlson index of comorbidity were calculated from 'primary' and 'associated' International Classification of Diseases, 10th revision, Australian Modification diagnoses. HFRS ≥5 was taken to signify frailty. Discharge home from hospital and death in hospital were modelled using logistic regression. Results There were 388 in-hospital arrest patients: 91% were aged ≥50 years, 34% were previously discharged in the past 6 months, 66% were unplanned admissions, 63% were non-cardiology-cardiothoracic admissions, 45% had a Charlson comorbidity index ≥2 and 19% were identified as frail. Discharge home occurred in 22%, discharge to another hospital 17% and death 62%. Of the frail patients, only 3 (4%) were discharged home, 12 (17%) were discharged to another hospital and 57 (79%) died in hospital. Fewer frail patients were discharged home compared with non-frail patients (4 vs 26%; odds ratio (OR) 0.13, P = 0.001). On multivariable analysis, patients were less likely to be discharged home if they had frailty (OR 0.24, P = 0.02), age ≥ 50 years (OR 0.36, P = 0.01), non-cardiology-cardiothoracic unit admission (OR 0.40, P = 0.001) and unplanned admission (OR 0.57, P = 0.04). Frail patients discharged to another hospital spent a median of 15 days (interquartile range 11-23) in the hospital post-arrest before leaving to continue inpatient care elsewhere. Frailty was associated with death in hospital on univariate analysis (79 vs 58%; OR 2.80, P = 0.001) but not after controlling for other factors. Conclusion Frail patients are unlikely to make a good recovery after in-hospital arrest. This should be taken into account when planning care with patients and their families.

BACKGROUND: Diabetic ketoacidosis (DKA) is an acute life-threatening metabolic complication of diabetes that imposes substantial burden on our healthcare system. There is a paucity of published data in Australia assessing factors influencing time to resolution of DKA and length of stay (LOS). AIMS: To identify factors that predict a slower time to resolution of DKA in adults with diabetes. METHODS: Retrospective audit of patients admitted to St Vincent's Hospital Melbourne between 2010 to 2014 coded with a diagnosis of 'Diabetic Ketoacidosis'. The primary outcome was time to resolution of DKA based on normalisation of biochemical markers. Episodes of DKA within the wider Victorian hospital network were also explored. RESULTS: Seventy-one patients met biochemical criteria for DKA; median age 31 years (26-45 years), 59% were male and 23% had newly diagnosed diabetes. Insulin omission was the most common precipitant (42%). Median time to resolution of DKA was 11 h (6.5-16.5 h). Individual factors associated with slower resolution of DKA were lower admission pH (P < 0.001) and higher admission serum potassium level (P = 0.03). Median LOS was 3 days (2-5 days), compared to a Victorian state-wide LOS of 2 days. Higher comorbidity scores were associated with longer LOS (P < 0.001). CONCLUSIONS: Lower admission pH levels and higher admission serum potassium levels are independent predictors of slower time to resolution of DKA. This may assist to stratify patients with DKA using markers of severity to determine who may benefit from closer monitoring and to predict LOS.

Objectives To evaluate the introduction of a document for recording the resuscitation plans of patients at a tertiary hospital. The ‘Acute Resuscitation Plan’ (ARP) was introduced in September 2014, superseding the ‘Not for Cardiopulmonary Resuscitation (CPR)’ form. Unlike the Not for CPR form, the ARP was relevant to patients with and without resuscitation limits. Design Retrospective audit of the records of all admissions to the hospital from January-June 2014 (Not for CPR period) and January-June 2015 (ARP period). Main outcomes Incidence of resuscitation plans; proportion of ARPs specifying consultation with the patient (or representative) and with senior medical staff and; proportion of ARPs among older patients and those with significant comorbidity. Results Resuscitation plans were present for 453/23,325 (1.9%) admissions in the Not for CPR period vs. 1,801/24,037 (7.5%) in the ARP period (OR 4.1, 95%CI 3.7-4.5, P

Opioid prescriptions have significantly increased in recent years and are used for a wide variety of indications. Electronic medical records of 45 patients who received naloxone by a rapid response team over an 18-month period were retrospectively reviewed. This study found inconsistencies in the management of possible opioid toxicity with variation in the total naloxone dose and number of doses administered. This highlights the importance of a standardised protocol for recognition and management of opioid overdose.

The purpose of this study is to compare cases of rapid response team (RRT) review for early deterioration (48 hours after admission), intermediate deterioration (48 to168 hours after admission), late deterioration (≥168 hours after admission), and cardiac arrest and to determine the association between duration of hospitalization before RRT review and mortality.This is a retrospective cohort study of RRT cases from a single hospital over 5 years (2009-2013) using administrative data and data for the first RRT attendance of each hospital episode.Of 2843 RRT cases, 971 (34.2%) were early deterioration, 917 (32.3%) intermediate, 775 (27.3%) late, and 180 (6.3%) cardiac arrest. Compared with early deterioration patients, late deterioration patients were older (median, 71 vs 69 years; P = .005), had a higher Charlson comorbidity index (median, 2 vs 1; P.001), more often had RRT review for respiratory distress (32.5% vs 23.5%; P.001), more often received RRT-initiated not for resuscitation orders (8.4% vs 3.9%; P.001), less often were discharged directly home (27.9% vs 58.4%; P.001), and more often died in hospital (30.6% vs 12.8%; P.001). Compared with early deterioration and adjusted for confounders, the odds ratio of death in hospital for late deterioration was 2.36 (1.81-3.08; P.001).Late deterioration is frequently encountered by the RRT and, compared with early deterioration, is associated with greater clinical complexity and a worse hospital outcome.

Background and Aim We have previously found high incidence of inflammatory bowel disease (IBD) in Australia. A population-based registry was established to assess disease severity, frequency of complications, and prognostic factors. Methods Incident cases were prospectively identified over 4 years. Early disease severity was assessed according to need for hospitalization and resective surgery and medication use. Results We report on the early outcomes (median 18 months, range 12–60 months) for 252 patients comprising 146 with Crohn's disease (CD), 96 with ulcerative colitis (UC), and 10 IBD undifferentiated. Eighty-seven percent of CD patients had inflammatory disease at diagnosis, and this reduced to 73% at 5 years (n = 38). Immunomodulators were prescribed in 57% of CD patients and 19% with UC. A third of all CD patients were hospitalized, the majority (77%) in the first 12 months. Risk factors for hospitalization included penetrating, perianal, and ileocolonic disease (P

To describe the frequency and hospital mortality of problems (diagnoses) encountered by a rapid response team (RRT), and to identify the most common diagnoses for RRT triggers and for treating units.For each RRT event in 2015 at a tertiary hospital for adults, we chose the diagnosis that best explained the RRT event from a pre-defined list after reviewing relevant test results and clinical notes.There were 937 RRT events during 700 admissions and there were 58 different RRT diagnoses in 11 diagnosis groups. The largest groups were neurological and consciousness problems (22.9%), circulatory problems (19.0%) and breathing problems (16.0%). The most common diagnoses were rapid atrial fibrillation (7.6%) and oversedation or narcosis (4.8%). When SpOThe RRT activation trigger provides only a general indication of the diagnosis. Some problems appear preventable and could provide a focus for unit-based quality initiatives. The mortality of some diagnoses is substantial, and this may help in setting treatment goals, but more work is needed to understand the association of RRT diagnosis and outcome.

Background: To compare and contrast the coronary heart disease (CHD) risk factors of lower socio-economic status public hospital patients with those of privately insured CHD patients before and after six months of telephone delivered coaching using The COACH Program. Methods: A retrospective observational study which contrasts the lifestyle and biomedical coronary risk factor status of 2256 public hospital patients with the same risk factors of 3278 patients who had private health insurance. All patients received an average of 5 coach sessions over 6 months. Results: The public hospital patients were four years younger and had multiple measures confirming their lower socio-economic status than their private hospital counterparts. At entry to the program, the public hospital patients had worse risk factor levels than the privately insured patients for total and LDL-cholesterol, triglycerides, fasting glucose, smoking and physical activity levels (P < 0.0001) but better status for systolic and diastolic blood pressures and alcohol intake. At exit from the program, many of these differences had diminished or disappeared. The public hospital patients had greater improvements in their risk factor status for total and LDL-cholesterol, fasting glucose, body weight, smoking status and physical activity level than did the privately insured patients (P < 0.05). Conclusions: This paper demonstrates that a program of initiating contact with patients with CHD, identifying treatment gaps in their management and coaching to achieve guideline recommended risk factor targets can help reduce health inequalities in such patients and thus benefit all patients in the context of ongoing secondary prevention.

a b s t r a c t Background: Arterial carbon dioxide tension (PaCO2) affects neuronal function and cerebral blood flow. However, its association with outcome in patients admitted to intensive care unit (ICU) after cardiac arrest (CA) has not been evaluated. Methods and results: Observational cohort study using data from the Australian New Zealand (ANZ) Inten- sive Care Society Adult-Patient-Database (ANZICS-APD). Outcomes analyses were adjusted for illness severity, co-morbidities, hypothermia, treatment limitations, age, year of admission, glucose, source of admission, PaO2 and propensity score. We studied 16,542 consecutive patients admitted to 125 ANZ ICUs after CA between 2000 and 2011. Using the APD-PaCO2 (obtained within 24 h of ICU admission), 3010 (18.2%) were classified into the hypo- (PaCO2 45 mmHg) group. The hypocapnia group, compared with the normocapnia group, had a trend toward higher in-hospital mortality (OR 1.12 (95% CI 1.00-1.24, p = 0.04)), lower rate of discharge home (OR 0.81 (0.70-0.94, p < 0.01)) and higher likelihood of fulfilling composite adverse outcome of death and no discharge home (OR 1.23 (1.10-1.37, p < 0.001)). In contrast, the hypercapnia group had similar in- hospital mortality (OR 1.06 (0.97-1.15, p = 0.19)) but higher rate of discharge home among survivors (OR 1.16 (1.03-1.32, p = 0.01)) and similar likelihood of fulfilling the composite outcome (OR 0.97 (0.89-1.06, p = 0.52)). Cox-proportional hazards modelling supported these findings. Conclusions: Hypo- and hypercapnia are common after ICU admission post-CA. Compared with normocap- nia, hypocapnia was independently associated with worse clinical outcomes and hypercapnia a greater likelihood of discharge home among survivors.

The 'Acute Resuscitation Plan' (ARP) is a document for recording the resuscitation plans of patients at a tertiary hospital for adult patients. The ARP was introduced at the hospital in September 2014, superseding the 'Not for Cardiopulmonary Resuscitation (CPR)' form. Unlike the Not for CPR form, the ARP was relevant to patients with and without resuscitation limits.To evaluate the introduction of the ARP.This study is a retrospective audit of the records of all admissions to the hospital from January to June 2014 (Not for CPR period) and January to June 2015 (ARP period). The main outcomes are the incidence of resuscitation plans, the proportion of ARP specifying consultation with the patient (or representative) and with senior medical staff, and the proportion of ARP among older patients and those with significant comorbidity.Resuscitation plans were present for 453 of 23 325 (1.9%) admissions in the Not for CPR period versus 1801 of 24 037 (7.5%) in the ARP period (odds ratio (OR) 4.1, 95% confidence interval (CI) 3.7-4.5, P0.001). A total of 42% of ARP specified 'care of the dying' in the event of arrest. Acknowledgement of the views of the patient (or representative) was indicated on 37% of ARP and of a senior physician on 28%. An ARP was not present for 67% of patients aged ≥90 years, 59% from aged care, 90% with metastatic cancer and 64% aged ≥80 years and with a Charlson comorbidity index ≥3.More patients had resuscitation plans after introducing the ARP. However, patients and senior physicians were often remote from the consultation process, and an ARP was not present for many patients likely to have a poor outcome from cardiopulmonary arrest.

a b s t r a c t We aimed to describe the characteristics of medical emergencies that occurred in the medical imaging department (MID) of a university hospital in Melbourne, Australia. A database of 'Respond Medical Emergency Team (MET)' and 'Respond Blue' calls was retrospectively examined for the period June 2003 to November 2010 in relation to events that occurred in the MID. The hospital medical imaging database was also examined in relation to these events and, where necessary, patients' notes were reviewed. Ethics approval was granted by the hospital ethics review board. There were 124 medical emergency calls in the MID during the study period, 28% Respond Blue and 72% Respond MET. Of these 124 calls, 26% occurred outside of usual work hours and 12% involved cardiac arrest. The most common reasons for the emergency calls were seizures (14%) and altered conscious state (13%). Contrast anaphylaxis precipitated the emergency in 4% of cases. In 83% of cases the emergency calls were for patients attending the MID for diagnostic imaging, the remainder being for a procedure. Of the scheduled imaging techniques, 45% were for computed tomog- raphy. The scheduled imaging was abandoned due to the emergency in 12% of cases. When performed, imaging informed patient management in 34% of cases in diagnostic imaging and in all cases in the context of image-guided procedures. Medical emergency calls in the MID often occurred outside usual work hours and were attributed to a range of medical problems. The emergencies occurred in relation to all imaging techniques and imaging informed patient management in many cases.

Low tidal volume ventilation reduces mortality in patients with acute lung injury (ALI) and may reduce the risk of ALI in ventilated patients. A previous audit of our ventilation practices showed poor adherence to low tidal volume ventilation, and we subsequently introduced written ventilation guidelines and an education program to change practice.To determine if adherence to low tidal volume ventilation (defined as mandatory tidal volumes of =?6.5 mL/ kg predicted body weight [PBW]) in ventilated patients was improved with a written guideline and staff education.Retrospective analysis of recorded mandatory ventilator settings from the clinical information system of a tertiary referral intensive care unit from 1 January 2012 to 31 December 2015, involving analysis of mandatory ventilator settings in relation to PBW to determine adherence to guidelines, and interrupted time-series analysis to assess the impact of education.Adherence to low tidal volume ventilation.The mean tidal volume for the cohort was 7.4 mL/ kg (SD, 1.3 mL/kg) PBW, and 760 patients (26.9%) received an average tidal volume during mandatory ventilation of ≤6.5 mL/kg PBW. Interrupted time-series analysis showed improved adherence after education, with an increase in adherence of 29.4% (95% CI, 19.3%-39.5%) from baseline. Multivariate logistic analysis found height, weight and staff education, but not sex, were associated with adherence to low tidal volume ventilation.Written protocols and education can influence clinician behaviour, with substantial improvements in adherence to low tidal volume ventilation. Efforts to improve adherence through ward-based education appear warranted and necessary. Adherence was strongly associated with patient height, which suggested that adherence was partly the result of chance rather than design.

OBJECTIVES Measurement of central venous oxygen (SvO2) levels remains an important method for the detection of circulatory shock. Plastic blood gas syringes have supplanted glass. These syringes are, however, permeable to atmospheric oxygen. Common sampling practices, including a delay between blood aspiration and analysis and continuous mixing of the sample, may promote equilibration of the blood sample with atmospheric oxygen and could result in over estimation of SvO2 levels. METHODS Pulmonary artery or central venous catheter blood samples were taken from 21 critically ill patients. Two venous blood gas samples were collected simultaneously in plastic syringes. One sample was continuously mixed through a gentle rotation. The other sample was not mixed. Blood gas analyses were undertaken on both samples at baseline and at 5, 10, 15, and 20 min. RESULTS Compared with baseline levels, the SvO2 increased significantly over time for both continuously mixed and nonmixed samples (P

Background The background of the study is a comparison of risk-adjusted mortality across hospitals from different jurisdictions is now common worldwide. Aim To examine temporal trends in risk-adjusted mortality in Victoria over the last decade. Methods Retrospective cohort study of 6.89 million adult (>14 years) patient episodes from 23 major Victorian public hospitals between 1999 and 2009. The primary outcome was in-hospital death. Three measures were calculated: the crude mortality rate, risk-adjusted mortality rate and standardised mortality ratio (SMR). The Hospital Outcome Prediction Equation (HOPE) was applied to generate estimates of predicted mortality that were used to compute the SMR and risk-adjusted mortality rates. The HOPE model includes 26 exogenous risk factors for which providers have no influence. The model was calibrated using the 2004–2005 data. Temporal mortality trends from 1999–2009 were evaluated using negative binomial regression for crude mortality and SMR estimates and random-intercept hierarchical logistic regression for risk-adjusted mortality. Results The study population included 84 423 in-hospital deaths (1.2%). Crude mortality risk declined from 1.5% in 2000 to 1.1% in 2005–2009 (incidence rate ratio (IRR): 0.96; 95% confidence interval (CI): 0.95–0.97; P < 0.001). There were 1.39 million episodes in the HOPE calibration cohort. Between 1999 and 2009, the SMR decreased from 1.4 to 0.9 (IRR = 0.91; 95% CI: 0.90–0.97; P < 0.001) and adjusted mortality risk declined from 2.1% to 0.9% (odds ratio = 0.94, 95% CI: 0.94–0.94, P < 0.001). Declining mortality trends were evident in the tertiary, metropolitan and regional peer groups (P < 0.001). Conclusion Analysis of in-hospital risk-adjusted mortality trends using the HOPE model indicates significant improvement in patient outcomes in the State of Victoria over the past decade.

To determine the epidemiology, in-hospital mortality, trends, patient characteristics and predictors of intensive care unit (ICU) readmission in Australia.A retrospective longitudinal study of data for 38 Australian ICUs extracted from the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS-ADP) for the years 2000-2007. Demographic, diagnostic, physiological and outcome data were analysed. A multivariate model was constructed to identify risk factors for ICU readmission. Outcomes examined included observed and risk-adjusted in-hospital mortality.A total of 247,103 patients were discharged alive from their first ICU admission; 13,598 (5.5%) were readmitted at least once. Variables associated with an odds ratio greater than 1.05 for readmission (p0.001) were an initial ICU admission source other than elective surgery, any chronic health variable on severity scoring, tertiary hospital ICU and discharge between 6 p.m. and 6 a.m. Five initial diagnoses were associated with an odds ratio (OR) greater than 2 for readmission (p0.001). In-hospital mortality in readmitted patients was 20.7% compared with 4.4% in those not readmitted. Readmission rates have not changed over the study period. After adjustment for illness severity and readmission propensity, ICU readmission remained significantly associated with in-hospital mortality (OR 5.4, 95%, confidence interval (CI) 5.1-5.7).Many risk factors for increased ICU readmission were identified in this study including ICU discharge between 6 p.m. and 6 a.m. This was the only modifiable variable studied. Prospective studies are required to identify other factors and to determine whether interventions may reduce ICU readmission and its high associated in-hospital mortality.

OBJECTIVE To describe the relationship between clinical practice and national guidelines for the transfusion of red blood cells (RBCs), fresh frozen plasma (FFP), platelets, and cryoprecipitate in Australian and New Zealand intensive care units (ICUs). SETTING Forty-seven ICUs over a 5-week period from August to September 2008. DESIGN Prospective, observational, multicentre, cohort study. PATIENTS A total of 874 patients receiving any type of blood transfusion. METHODS All patients who were transfused at least one unit of any blood component were included. Patient-specific and blood-component specific data were gathered. Pre-transfusion haemoglobin, platelet count, international normalised ratio (INR), and fibrinogen levels were compared to national guidelines. RESULTS Of all 874 patients, 757 received RBCs (86.6%), 231 (26.4%) received platelets, 340 (38.9%) received FFP, and 78 (8.9%) received cryoprecipitate. Bleeding was the reason for administration of RBCs in 46%, FFP in 55%, and platelets in 47% of transfusions. The mean (SD) pre-transfusion haemoglobin was 77.6 (9.5) g/l, while the geometric means (95% CI) for platelet count, INR, and fibrinogen were 67.0 (59.7-75.3) x 10(9)/l, 1.84 (1.76-1.93), and 1.4 (1.1-1.8) g/l, respectively. The proportions of transfusions not adherent to guidelines were 2% for RBC, but 53% for platelets, 29% for FFP, and 88% for cryoprecipitate (RBC vs. other transfusion p < 0.001 for all). CONCLUSIONS Transfusion practice of RBCs in Australian and New Zealand ICUs is restrictive and is concordant with guidelines. However, the transfusion of other blood components is not.

Background: The aim of this study was to validate a risk-adjusted hospital outcome prediction equation (HOPE) using a statewide administrative dataset. Methods: Retrospective observational study using multivariate logistic regression modelling. Calibration and discrimination were assessed by standardized mortality ratio (SMR), area under the receiver operating characteristic plot (ROC AUC), Hosmer–Lemeshow contingency tables and goodness-of-fit statistic in an independent dataset, and in all 23 important tertiary, metropolitan and regional hospitals. The dependent variable was in-hospital death. All consecutive adult hospital separations between 1 July 2004 and 30 June 2006, excluding obstetric and day-case only admissions, from all acute health services within the State of Victoria, Australia were included. Results: A total of 379 676 consecutive records (1 July 2004 to 30 June 2005) was used to derive the HOPE model. Six variables (age, male sex, admission diagnosis, emergency admission, aged-care resident and inter-hospital transfer) were selected for inclusion in the final model. It was validated in the 384 489 consecutive records from the following year (1 July 2005 to 30 June 2006). The 95% confidence interval for the SMR was 0.98–1.02, and for the ROC AUC, 0.87–0.88. Discrimination and (one or more) calibration criteria were achieved in 22 (96%) of the 23 hospitals. Conclusion: The HOPE model is a simple risk-adjusted outcome prediction tool, based on six variables from data that are routinely collected for administrative purposes and appears to be a reliable predictor of hospital outcome.

We hypothesise that there exists a substantial and growing group of "persistently critically ill" patients who appear to be intensive care unit-dependent because of a cascade of critical illnesses rather than their original ICU admitting diagnosis. These persistently critically ill patients are those who remain in the ICU because of ongoing complications of care that continue after their reason for admission has been treated and is no longer active. We believe such patients can be distinguished from patients currently labelled as "chronic critical illness" or "prolonged mechanical ventilation". We further believe that their primary problem is not simply failure to wean from mechanical ventilation due to muscle weakness and impaired gas exchange. We outline a program of clinician consultation, epidemiological research, consensus conference and validation to develop a useful definition of persistent critical illness, with the aim of supporting investigations in preventing persistence, and improving the care of patients so affected.

Low tidal volume ventilation (LTVV) has been shown to reduce mortality of patients with acute lung injury (ALI) but uptake by clinicians has been low. Recent studies have shown that LTVV results in survival benefit at 24 months after discharge and, importantly, benefits patients without ALI.To determine adherence to LTVV in patients on mechanical ventilation (MV).Retrospective analysis of ventilator settings recorded within the clinical information system of a 15-bed general ICU in a tertiary referral hospital, between 1 January 2000 and 31 May 2013.Analysis of mandatory MV with volume or pressure control.Adherence to LTVV (_6.5 mL/ kg predicted body weight [PBW]).We studied 4923 patients with a median age of 66 years (interquartile range [IQR], 57-74 years), and a median Acute Physiology and Chronic Health Evaluation II score of 16 (IQR, 13-19). Included were 3486 men (70.8%), and 3386 (66.8%) had undergone cardiac surgery. There were 249 450 ventilator measurements, with a median per patient of 75 measurements (IQR, 17-255 measurements). The median tidal volume was 8.15 mL/kg PBW (IQR, 7.15- 9.34 mL/kg PBW) for an adherence of 13.4%. Independent factors associated with adherence were sex, high inspiratory pressures, high positive end expiratory pressure and low PaO2/FiO2 ratio.Adherence to LTVV in a general cohort of ICU patients was low, but it was better in patients with more severe lung disease. Overestimation of PBW may have contributed to our findings. Regular auditing of LTVV adherence might be considered a clinical indicator of good MV practice.

BACKGROUND AND OBJECTIVE Salbutamol (SAL) has systemic effects that may adversely influence ventilation in asthmatic patients. The authors sought to determine the magnitude of this effect and mechanisms by which i.v. SAL affects ventilation. METHODS A prospective study of nine healthy subjects (eight men, one woman; age 23 +/- 1.4 years (SD)) was undertaken. Each subject received i.v. SAL at 5, 10 and 20 microg/min each for 30 min at each dose and was observed for 1 h post infusion. Minute ventilation ((VE)), oxygen consumption (VO(2)), CO(2) production (VCO(2)), occlusion pressure (P(0.1)), heart rate, blood pressure, respiratory rate, glucose, arterial blood gases, lactate and potassium (K(+)) were recorded at baseline and at 30-min intervals. The effect of 100% oxygen on (VE) and P(0.1) during SAL infusion at 20 microg/min was observed. Results are expressed as mean +/- SEM. RESULTS V(E) was significantly increased at 20 microg/min SAL (37.8 +/- 12.1%, P = 0.01), as were VO(2) (22.5 +/- 5.1%, P < 0.01) and VCO(2) (40.9 +/- 10.6%, P < 0.01). Ventilation was in excess of metabolic needs as demonstrated by a rise in the respiratory exchange ratio (0.87 +/- 0.03 to 0.99 +/- 0.04, P < 0.05). Serum lactate rose by 124 +/- 30.4% from baseline to 20 microg/min (1.1 +/- 0.1 to 2.3 +/- 0.25 mmol/L, P < 0.01) and base excess decreased (0.89 +/- 0.56 to vs. -1.75 +/- 0.52 mmol/L, P < 0.01) consistent with a lactic acidosis contributing to the excess ventilation. There was no significant differences in (VE) or P(0.1) with F(I)O(2) = 1.0, suggesting peripheral chemoreceptor stimulation was not responsible for the rise in (VE). At 20 microg/min SAL, K(+) fell significantly from baseline (3.8 +/- 0.06 to 2.8 +/- 0.09 mmol/L, P < 0.001). CONCLUSION Systemic SAL imposes ventilatory demands by increasing metabolic rate and serum lactate. This may adversely affect patients with severe asthma with limited ventilatory reserve.

To compare the admission characteristics, discharge destination and mortality of patients reviewed by the rapid response team (RRT) for deterioration with those of other hospital patients; and to determine the association between RRT review for deterioration and mortality.Acute admissions of adult patients to a tertiary hospital between 1 January 2008 and 31 December 2011 were identified from administrative data. Data for each patient's first admission were merged with RRT data on the first RRT event of each admission, if any. RRT events involving cardiac arrest were classified as arrest events and all others as deterioration events.Of 43 385 patients in the cohort, 1117 (2.57%) had RRT review for deterioration and 91 (0.21%) for cardiac arrest. Deterioration events occurred a median of 3.23 days after admission. Advanced treatments were instituted in 38.59% of deterioration events, and a new not-for resuscitation order for 5.55%. Compared with those not reviewed by the RRT, patients in the deterioration group were older (median, 70 v 60 years, P0.001) and had a higher Charlson comorbidity index (median, 1 v 0, P0.001). They also more often died in hospital (18.80% v 1.42%, P0.001) or were discharged to another hospital (37.51% v 13.39%, P0.001) and more often died in the 90 days after admission (24.44% v 3.48%, P0.001). Their adjusted odds ratio of death in the 90 days after admission was 5.85 (95% CI, 4.97-6.89, P0.001).Patients reviewed for deterioration were older and had greater comorbidity than patients the RRT was not called to review. RRT review for deterioration was an independent risk factor for mortality.

Review of resource use and patient outcomes of intensive care unit services over time provides insights into service delivery and safety.To examine temporal trends in resource consumption and risk-adjusted mortality of adult ICU patients in Victoria.Retrospective cohort study of 214 619 adult ICU admissions recorded from 23 major hospitals over 12 years from 1 July 1999 to 30 June 2011.Primary outcomes were population rates of ICU admission and mechanical ventilation (MV), ICU and hospital length of stay, and hospital survival. Secondary outcomes included average ICU and MV bed numbers. Administrative data were derived from the Victorian Admitted Episodes Dataset and the Australian Bureau of Statistics. The Critical Care Outcome Prediction Equation informed estimates for risk-adjusted mortality. Temporal mortality trends were evaluated for outcome estimates and hierarchical logisticregression trends were evaluated for risk-adjusted mortality.Of ICU admissions, 104 103 (48.5%) were patients who received MV, and 87.6% ICU admissions were adults who survived to hospital discharge. There was a decline in the risk-adjusted mortality (odds ratio, 0.967 per year; 95% CI, 0.963-0.971; P0.001). Similar results were found in 17 hospitals (74%) and in nine of 10 major diagnostic subgroups. There was an increase of 5.2 occupied ICU beds per year (range, ?4.2 ICU beds per year; P=0.002). Despite ICU admissions being a minority cohort (2.5% of public hospital admissions) this group used 8.6% of hospital bed-days and attracted 19.5% of funding.There was an increase in ICU resource availability and evidence of improvement in hospital survival, suggesting improved quality of care. These evaluation methods may be useful in monitoring statewide capacity, service delivery and patient safety.

Background: Hepatitis C virus (HCV) infection is a significant problem in the Australian community. Over the past few years, the number of patients with diagnosed hepatitis C has increased greatly. The aims of the present study were to define the clinical features of a large group of patients with chronic HCV infection and to examine changes occurring in the referral base and epidemiological characteristics of this group since analysis of the first 342 patients in 1994. Methods: The study included 1546 consecutive anti-HCV-positive patients who had been referred to St Vincent's Hospital from January 1990 to June 1998. Clinical and laboratory data were collected on all patients. Results: Referrals from general practitioners increased from 31% to 70% of all patients between 1990–1993 and 1994–1998. A history of injecting drug use (IDU) was present in 64% of the patients. While 89% of the IDU group was Australasian born, 49% of those in the sporadic group were born overseas. Cirrhosis was found in 18% of biopsied patients. Age, infection duration, age at infection, Mediterranean or Asian origin and a history of transfusion or lack of HCV risk factors were associated with cirrhosis on univariate analysis. Patient age was the only independent predictor of cirrhosis. Conclusion: The majority of patients with HCV are diagnosed in general practice. A risk factor for infection is identified in 82% of patients. While our reported prevalence of cirrhosis may be an overestimate of that in the overall HCV community, the ultimate disease burden is likely to be significant. (Intern Med J 2001; 31: 90–96)

Acute limb compartment syndrome is a surgical emergency associated with significant morbidity if not diagnosed promptly and treated effectively. We describe a case of severe and eventually lethal acute limb compartment syndrome, which complicated veno-arterial extracorporeal membrane oxygenation in a previously well young woman who had suffered an unexplained cardiac arrest. We recommend that intensive care units develop clinical practice guidelines for the use of extracorporeal membrane oxygenation therapy in order to minimise the risk of similar adverse events in the future.