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The changing phenotype of coronarvirus disease 2019 (COVID‐19) may quickly render guideline‐recommended interventions obsolete. We developed a 40‐question clinician survey in consultation with the Australasian COVID‐19 Trial site investigators. The survey was designed to assess clinician perceptions of the current treatment strategies and future research priorities in the management of non‐critically ill patients admitted to hospital with SARS‐CoV‐2 infection. There were 84 complete responses from predominantly Australian and New Zealand clinicians. The perceived prevalence of patients with incidental COVID‐19, nosocomial infection, underlying illness exacerbated by COVID‐19, and/or immunocompromised status suggests new populations to target. The results highlighted clinician interest in antiviral therapies for future research in both immunocompetent and immunocompromised cohorts. These survey results underscore the need for ongoing surveillance of COVID‐19 disease phenotypes and clinician and patient priorities for future research. [ABSTRACT FROM AUTHOR]

Rationale: Whether biomarkers can identify subgroups of patients with septic shock with differential treatment responses to hydrocortisone is unknown.Objectives: To determine if there is heterogeneity in effect for hydrocortisone on mortality, shock resolution, and other clinical outcomes based on baseline cortisol, aldosterone, and ascorbic acid concentrations.Methods: From May 2014 to April 2017, we obtained serum samples from 529 patients with septic shock from 22 ICUs in Australia and New Zealand.Measurements and Main Results: There were no significant interactions between the association with 90-day mortality and treatment with either hydrocortisone or placebo for total cortisol (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.02-1.16 vs. OR, 1.07; 95% CI, 1.00-1.13; P = 0.70), free cortisol (OR, 1.20; 95% CI, 1.04-1.38 vs. OR, 1.16; 95% CI, 1.02-1.32; P = 0.75), aldosterone (OR, 1.01; 95% CI, 0.97-1.05 vs. OR, 1.01; 95% CI, 0.98-1.04; P = 0.99), or ascorbic acid (OR, 1.11; 95% CI, 0.89-1.39 vs. OR, 1.05; 95% CI, 0.91-1.22; P = 0.70), respectively. Similar results were observed for the association with shock resolution. Elevated free cortisol was significantly associated with 90-day mortality (OR, 1.13; 95% CI, 1.00-1.27; P = 0.04), but total cortisol, aldosterone, and ascorbic acid were not.Conclusions: In patients with septic shock, there was no heterogeneity in effect of adjunctive hydrocortisone on mortality, shock resolution, or other clinical outcomes based on cortisol, aldosterone, and ascorbic acid concentrations. Plasma aldosterone and ascorbic acid concentrations are not associated with outcome. [ABSTRACT FROM AUTHOR]

Background: The H1N1 Influenza A pandemic arrived in Australia in early May 2009. In Queensland, the highest number of H1N1 cases were admitted to the intensive care unit when compared with the other Australian states. While many recent studies examining the H1N1 pandemic have focussed on service delivery and disease epidemiology, few have explored the lived experiences of frontline health care workers caring for the patients in the intensive care unit. Objectives: The purposes of this study were to: document and describe the lived experiences of the nursing and medical staff caring for patients in the intensive care unit during the H1N1 pandemic; to validate the staffs’ experiences; and to assist in informing future pandemic planning by highlighting the collective experiences of these frontline health care workers. Design: A phenomenological study method was used. Setting and participants: 34 staff from a tertiary referral hospital in Brisbane, Australia participated in the study. Methods: Data was collected using an open ended questionnaire and focus groups. The resulting responses were analysed using Colaizzi''s framework to discover regular patterns of meaning that emerged. Results: Eight common themes emerged: the wearing of personal protective equipment; infection control procedures; the fear of contracting and transmitting the disease; adequate staffing levels within the intensive care unit; new roles for staff; morale levels; education regarding extracorporeal membrane oxygenation; and the challenges of patient care. These eight themes articulate the lived experience of the staff during the height of the H1N1 Influenza pandemic period. Conclusions: Planning for a pandemic situation is invariably difficult due to the unpredictable nature of the event itself. Recommendations for future pandemic planning which can be drawn from this study include the appointment of a dedicated infection control representative to provide information and support regarding infection control matters; the maintenance of effective communication channels is crucial; and the increased staffing requirements across nursing, medical, allied health and ancillary staff to cope with the higher patient numbers and acuity must be anticipated and planned for. [Copyright &y& Elsevier]

Background: Infusion sets (comprising the tubing, measuring burettes, fluid containers, transducers) that are connected to invasive vascular devices are changed on a regular basis in an effort to reduce bacterial colonisation and bloodstream infection. There is a balance between reducing infection and creating unnecessary waste. Current evidence suggests that for central venous catheters (CVCs), changing infusion sets at 7 days does not increase infection risks., Objectives: The objective of this study was to describe the current unit guidelines in Australian and New Zealand intensive care units (ICUs) for changing infusion sets for CVCs., Methods: prospective cross-sectional point prevalence study, as a part of the 2021 Australian and New Zealand Intensive Care Society Point Prevalence Program., Participants: Australia and New Zealand (ANZ) adult ICUs and their patients on the day of the study., Results: Data were collected from 51 ICUs across ANZ. One-third of these (16/49) ICUs had a guideline that specified a 7-day replacement period, with the rest having a more frequent replacement period., Conclusion: Most ICUs participating in this survey had policies to change their CVC infusion tubing in 3-4 days, and recent high-level evidence supports an update to extend this to 7 days. There remains work to be done to spread this evidence to ANZ ICUs and improve environmental sustainability initiatives., (Copyright © 2023 Australian College of Critical Care Nurses Ltd. All rights reserved.)

Background: Dysphagia occurs in intensive care unit (ICU) patients. However, there is a lack of epidemiological data on the prevalence of dysphagia in adult ICU patients., Objectives: The objective of this study was to describe the prevalence of dysphagia in nonintubated adult patients in the ICU., Methods: A prospective, multicentre, binational, cross-sectional point prevalence study was conducted in 44 adult ICUs in Australia and New Zealand. Data were collected in June 2019 on documentation of dysphagia, oral intake, and ICU guidelines and training. Descriptive statistics were used to report demographic, admission, and swallowing data. Continuous variables are reported as means and standard deviations (SDs). Precisions of estimates were reported as 95% confidence intervals (CIs)., Results: Of the 451 eligible participants, 36 (7.9%) were documented as having dysphagia on the study day. In the dysphagia cohort, the mean age was 60.3 years (SD: 16.37) vs 59.6 years (SD: 17.1) and almost two-thirds were female (61.1% vs 40.1%). The most common admission source for those patients with dysphagia were from the emergency department (14/36, 38.9%), and seven of 36 (19.4%) had a primary diagnosis of trauma (odds ratio: 3.10, 95% CI 1.25 - 7.66). There were no statistical differences in Acute Physiology and Chronic Health Evaluation (APACHE II) scores between those with and without a dysphagia diagnosis. Patients with dysphagia were more likely to have a lower mean body weight of 73.3 kg vs 82.1 kg than patients not documented as having dysphagia (95% CI of mean difference: 0.43 to 17.07) and require respiratory support (odds ratio: 2.12, 95% 1.06 to 4.25). The majority of patients with dysphagia were prescribed modified food and fluids in the ICU. Less than half of ICUs surveyed reported unit-level guidelines, resources, or training for management of dysphagia., Conclusions: The prevalence of documented dysphagia in adult ICU nonintubated patients was 7.9%. There were a higher proportion of females with dysphagia than previously reported. Approximately two-thirds of patients with dysphagia were prescribed oral intake, and the majority were receiving texture-modified food and fluids. Dysphagia management protocols, resources, and training are lacking across Australian and New Zealand ICUs., Competing Interests: Conflict of interest The authors declare they have no relevant financial or nonfinancial interests., (Copyright © 2023 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Introduction: Intensive care unit clinical research is often implemented by specialised research coordinators (RCs). Clinical research activity within Australian and New Zealand intensive care units has escalated, particularly during the COVID-19 pandemic. Growth of the intensive care RC workforce to match research demand is poorly understood., Aim: The aim of this study was to repeat an Intensive Care Research Coordinator Interest Group workforce survey conducted in 2004 and 2009 to describe the current workforce and role satisfaction and also to determine reported symptoms of depression, anxiety, stress, and burnout in Australian and New Zealand intensive care RCs., Methods: In April 2021, an online anonymised survey was distributed to intensive care RCs to complete demographic and workforce questions, the McCloskey/Mueller Satisfaction Scale, the Depression Anxiety Stress Scales-21, and the Maslach Burnout Inventory-Human Services Survey for Medical Personnel., Results: Of 128 Intensive Care Research Coordinator Interest Group eligible members, 98 (77%) completed the survey. Respondents were mainly women (91%), the median age was 47 years, 37% have a postgraduate qualification, and a third have over 10 years of RCC experience (31%). Half do not have permanent employment (52%). The mean Depression Anxiety Stress Scales-21 scores were within the normal range, and respondents reported symptoms of depression (21 [21%]), anxiety (23 [23%]), and stress (26 [27%]). Nearly half of the respondents (44%) exhibited an early symptom of burnout by reporting problematic experiences of work. The overall role satisfaction score was 3.5/5 (neutral; neither satisfied nor dissatisfied)., Conclusions: Intensive care RCs are an experienced group of professionals with limited satisfaction in the role. One-fifth of the ICU RCs experienced depression, anxiety, or stress symptoms, with close to half reporting signs of burnout. These results highlight the need to address areas of concern to ensure retention of this specialised intensive care workforce., (Crown Copyright © 2022. Published by Elsevier Ltd. All rights reserved.)

Background: SARS-CoV-2 infection is associated with a significant risk of hospitalisation, death, and prolonged impact on quality of life. Evaluation of new treatment options and optimising therapeutic management of people hospitalised with SARS-CoV-2 infection remains essential, but rapid changes in pandemic conditions and potential therapies have limited the utility of traditional approaches to randomised controlled trials., Methods: ASCOT ADAPT is an international, investigator-initiated, adaptive platform, randomised controlled trial of therapeutics for non-critically ill patients hospitalised with COVID-19. The study design is open label and pragmatic. Potential participants are hospitalised adults with PCR confirmed, symptomatic, SARS-CoV-2 infection, within 14 days of symptom onset. Domains include antiviral, antibody and anticoagulant interventions, with a composite primary outcome of 28-day mortality or progression to intensive-care level respiratory or haemodynamic support. Initial interventions include intravenous nafamostat and variable dose anticoagulation. A range of secondary endpoints, and substudies for specific domains and interventions are outlined., Discussion: This paper presents the trial protocol and management structure, including international governance, remote site monitoring and biobanking activities and provides commentary on ethical and pragmatic considerations in establishing the ASCOT ADAPT trial under pandemic conditions., Trial Registration: Australian and New Zealand Clinical Trials Registry (ACTRN12620000445976) and ClinicalTrials.gov (NCT04483960)., (© 2022. The Author(s).)

Background: Device-related pressure injuries (DRPIs) are an ongoing iatrogenic problem evident in intensive care unit (ICU) settings. Critically ill patients are at high risk of developing pressure injuries caused by devices., Objective: The aim of the study was to determine the prevalence of DRPI in critically ill patients in intensive care and the location, stage, and attributable device of DRPI and describe the products and processes of care used to prevent these injuries., Methods: This was a prospective, multicentre, cross-sectional point prevalence study of patients aged more than 16 years in Australian and New Zealand ICUs. The study was part of the Australian and New Zealand Intensive Care Society Clinical Trials Group Point Prevalence Program coordinated by The George Institute for Global Health., Main Outcome Measure: Identification of DRPI on the study day was the main outcome measure., Results: Of the 624 patients included from 44 participating ICUs, 27 were found to have 35 identified DRPIs, giving a point prevalence DRPI rate of 4.3% (27/624). Study patients had a mean age of 59 years, and 60.3% were men. Patients with DRPI compared with patients without DRPI were significantly heavier (median: 92 kg versus 80 kg, respectively, p = 0.027), were less likely to survive the ICU (63.0% versus 85.9%, respectively, p = 0.015), had higher Acute Physiology and Chronic Health Evaluation II scores at admission to the ICU (median: 20 versus 16, respectively, p = 0.001), received mechanical ventilation more often (88.9% versus 43.5%, respectively, p < 0.001), and were more frequently diagnosed with respiratory conditions (37.0% versus 18.6%, respectively, p = 0.022). Processes of care activities were surveyed in 42 ICUs. Most DRPIs were attributed to endotracheal tubes and other respiratory devices. Forty-two ICUs reported processes of care to prevent DRPI, and just more than half of the participating sites (54.8%, 23/44) reported a dedicated ICU-based protocol for prevention of DRPI., Conclusion: DRPIs pose a burden on patients in the ICU. Our study showed a DRPI prevalence comparable with other studies. Prevention strategies targeting DRPI should be included in ICU-specific pressure injury prevention guidelines or protocols., Competing Interests: Conflict of interest All authors declare that they have no conflicts of interest., (Copyright © 2021 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Aim: The aim of the study was to determine levels of depression, anxiety, and stress symptoms and factors associated with psychological burden amongst critical care healthcare workers in the early stages of the coronavirus disease 2019 pandemic., Methods: An anonymous Web-based survey distributed in April 2020. All healthcare workers employed in a critical care setting were eligible to participate. Invitations to the survey were distributed through Australian and New Zealand critical care societies and social media platforms. The primary outcome was the proportion of healthcare workers who reported moderate to extremely severe scores on the Depression, Anxiety, and Stress Scale-21 (DASS-21)., Results: Of the 3770 complete responses, 3039 (80.6%) were from Australia. A total of 2871 respondents (76.2%) were women; the median age was 41 years. Nurses made up 2269 (60.2%) of respondents, with most (2029 [53.8%]) working in intensive care units. Overall, 813 (21.6%) respondents reported moderate to extremely severe depression, 1078 (28.6%) reported moderate to extremely severe anxiety, and 1057 (28.0%) reported moderate to extremely severe stress scores. Mean ± standard deviation values of DASS-21 depression, anxiety, and stress scores amongst woman vs men was as follows: 8.0 ± 8.2 vs 7.1 ± 8.2 (p = 0.003), 7.2 ± 7.5 vs 5.0 ± 6.7 (p < 0.001), and 14.4 ± 9.6 vs 12.5 ± 9.4 (p < 0.001), respectively. After adjusting for significant confounders, clinical concerns associated with higher DASS-21 scores included not being clinically prepared (β = 4.2, p < 0.001), an inadequate workforce (β = 2.4, p = 0.001), having to triage patients owing to lack of beds and/or equipment (β = 2.6, p = 0.001), virus transmission to friends and family (β = 2.1, p = 0.009), contracting coronavirus disease 2019 (β = 2.8, p = 0.011), being responsible for other staff members (β = 3.1, p < 0.001), and being asked to work in an area that was not in the respondents' expertise (β = 5.7, p < 0.001)., Conclusion: In this survey of critical care healthcare workers, between 22 and 29% of respondents reported moderate to extremely severe depression, anxiety, and stress symptoms, with women reporting higher scores than men. Although female gender appears to play a role, modifiable factors also contribute to psychological burden and should be studied further., (Copyright © 2020 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Pressure injuries (PIs) are a patient safety issue that impact patient outcomes. Intensive care unit (ICU) patients are at high risk of PIs., Objectives: To report the prevalence and classification of documented PIs in adult ICU patients, the use of pressure injury risk assessment tools, and support surface management as a part of the prevention of PIs., Methods: This was a prospective, single-day, multicentre, cross-sectional study of patients aged ≥ 16 years admitted to adult ICUs in Australia and New Zealand (ANZ), August 2016 as part of the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS-CTG) Point Prevalence Program., Findings: Data were collected on 671 patients (58% male) in 47 ICUs. The mean [standard deviation] age and weight were 60.2 years [17.2 years] and 82.1 kg [29.7 kg], respectively, with a severity of illness score (Acute Physiology and Chronic Health Evaluation [APACHE] II) of 18.2 [8.4]. PIs were reported in 10% (70/671) of patients. Patients with a PI had a mean APACHE II score of 22.5 [standard deviation; 7.7], and 57.1% (40/70) met the criteria for sepsis on the study day. There were 107 PIs documented on the study day (N = 107) in the 70 patients with nearly half of PIs present on ICU admission (46.7%; 50/107). The sacrum was the most common location for PIs (28.9%; 31/107) and then the heels (15.9%; 17/107). All units routinely use a risk of PI assessment tool and were cared for on an active or reactive support surface. Patients with a PI were more often moved to an active support surface., Conclusions: The prevalence rate was reported at 10% for PIs for adult intensive care patients on the study day. More than half of the patients with a PI had signs of sepsis on the study day and a higher severity of illness, and more were cared for on active support surfaces. Most PIs were located at the sacrum and then the heels. All clinical sites routinely used a PI risk assessment tool., Competing Interests: Conflict of interest None declared., (Crown Copyright © 2020. Published by Elsevier Ltd. All rights reserved.)

Purpose: It is unknown whether protocols targeting systematic prevention and treatment of fever achieve lower mean body temperature than usual care in intensive care unit (ICU) patients. The objective of the Randomised Evaluation of Active Control of temperature vs. ORdinary temperature management trial was to confirm the feasibility of such a protocol with a view to conducting a larger trial., Methods: We randomly assigned 184 adults without acute brain pathologies who had a fever in the previous 12 h, and were expected to be ventilated beyond the calendar day after recruitment, to systematic prevention and treatment of fever or usual care. The primary outcome was mean body temperature in the ICU within 7 days of randomisation. Secondary outcomes included in-hospital mortality, ICU-free days and survival time censored at hospital discharge., Results: Compared with usual temperature management, active management significantly reduced mean temperature. In both groups, fever generally abated within 72 h. The mean temperature difference between groups was greatest in the first 48 h, when it was generally in the order of 0.5 °C. Overall, 23 of 89 patients assigned to active management (25.8%) and 23 of 89 patients assigned to usual management (25.8%) died in hospital (odds ratio 1.0, 95% CI 0.51-1.96, P = 1.0). There were no statistically significant differences between groups in ICU-free days or survival to day 90., Conclusions: Active temperature management reduced body temperature compared with usual care; however, fever abated rapidly, even in patients assigned to usual care, and the magnitude of temperature separation was small., Trial Registration: Australian and New Zealand Clinical Trials Registry Number, ACTRN12616001285448.

Objectives: To compare estimates of the incidence and mortality of sepsis and septic shock among patients in Australian intensive care units (ICUs) according to clinical diagnoses or binational intensive care database (ANZICS CORE) methodology., Design, Setting, Participants: Prospective inception cohort study (3-month inception period, 1 October - 31 December 2016, with 60-day follow-up); daily screening of all patients in a tertiary hospital 60-bed multidisciplinary ICU., Main Outcomes: Diagnoses of sepsis and septic shock according to clinical criteria and database criteria; in-hospital mortality (censored at 60 days)., Results: Of 864 patients admitted to the ICU, 146 (16.9%) were diagnosed with sepsis by clinical criteria and 98 (11%) according to the database definition (P < 0.001); the sensitivity of the database criteria for sepsis was 52%, the specificity 97%. Forty-nine patients (5.7%) were diagnosed with septic shock by clinical criteria and 83 patients (9.6%) with the database definition (P < 0.001); the sensitivity of the database criteria for septic shock was 65%, the specificity 94%. In-hospital mortality of patients diagnosed with sepsis was greater in the clinical diagnosis group (39/146, 27%) than in the database group (17/98, 17%; P = 0.12); for septic shock, mortality was significantly higher in the database group (18/49, 37%) than in the clinical diagnosis group (13/83, 16%; P = 0.006)., Conclusions: When compared with the reference standard - prospective clinical diagnosis - ANZICS CORE database criteria significantly underestimate the incidence of sepsis and overestimate the incidence of septic shock, and also result in lower estimated hospital mortality rates for each condition.

Objective: To determine the frequency of pharmacological and physical cooling in non-elective general intensive care unit patients without neurological abnormalities in Australia and New Zealand, and to establish the indications for antipyretics, the prevalence of fever, and the methods of temperature measurement., Design, Setting and Participants: A point prevalence study conducted on two days in 2010, in 38 ICUs in Australia and New Zealand, examining non-elective (emergency) patients admitted with sepsis and other inflammatory abnormalities but without neurological abnormalities., Results: Of 506 general ICU patients surveyed on the study days, 311 had sepsis or other inflammatory abnormalities and no neurological abnormalities. These patients had a mean peak temperature of 37.3°C (SD, 0.8°C). In 100 patients (32.2%), the peak temperature was above 38°C. Paracetamol was the most common antipyretic used (152/311; 48.9%) and was administered for pain in 92/152 patients (60.5%), for pain and fever in 26/152 patients (17.1%), and for fever alone in 14/152 patients (9.2%). Patients who received paracetamol for fever had a mean peak recorded temperature of 38.3°C (SD, 0.8°C). Temperature measurements were mainly non-core (251/ 311; 81%) with axillary (116/311; 37%) and tympanic (110/ 311; 35%) measurements the most common., Conclusion: Pharmacological antipyretics are used regularly for pain management rather than fever management, with paracetamol the most common antipyretic therapy. The use of NSAIDS and physical cooling is rare. Non-core temperature measurements were common.