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Background Healthcare workers (HCWs) have frequently become infected with severe acute respiratory syndrome coronavirus 2 whilst treating patients with coronavirus disease 2019 (COVID-19). A variety of novel devices have been proposed to reduce COVID-19 cross-contamination. Objectives The aim of the study was (i) to test whether patients and HCWs thought that a novel patient isolation hood was safe and comfortable and (ii) to obtain COVID-19 infection data of hospital HCWs. Methods This is a prospective cohort study of 20 patients, entailing HCW/patient questionnaires and safety aspects of prototype isolation hoods. COVID-19 data of HCWs were prospectively collected. Assessment of the hood's safety and practicality and adverse event reporting was carried out. Outcome measures The outcome measures are as follows: questionnaire responses, adverse event reporting, rates of infections in HCWs during the study period (20/6/2020 to 21/7/2020), and COVID-19 infections in HCWs reported until the last recorded diagnosis of COVID-19 in HCWs (20/6/2020 to 27/9/2020). Results Of the 64 eligible individual HCW surveys, 60 surveys were overall favourable (>75% questions answered in favour of the isolation hood). HCWs were unanimous in perceiving the hood as safe (60/60), preferring its use (56/56), and understanding its potential COVID-19 cross-contamination minimisation (60/60). All eight patients who completed the questionnaire thought the isolation hood helped prevent COVID-19 cross infection and was safe and comfortable. There were no reported patient safety adverse events. The COVID-19 attack rate from 20/6/2020 to 27/9/2020 among registered nurses was as follows: intensive care units (ICUs), 2.2% (3/138); geriatric wards, 13.2% (26/197); and COVID-19 wards, 18.3% (32/175). The COVID-19 attack rate among medical staff was as follows: junior staff, 2.1% (24/932); senior staff, 0.7% (4/607); aged care/rehabilitation, 6.7% (2/30); and all ICU medical staff, 8.6% (3/35). Conclusions The isolation hood was preferred to standard care by HCWs and well tolerated by patients, and after the study, isolation hoods became part of standard ICU therapy. There was an association between being an ICU nurse and a low COVID-19 infection rate (no causality implied). ICU HCWs feel safer when treating patients with COVID-19 using an isolation hood.

A circular economy involves maintaining manufactured products in circulation, distributing resource and environmental costs over time and with repeated use. In a linear supply chain, manufactured products are used once and discarded. In high-income nations, health care systems increasingly rely on linear supply chains composed of single-use disposable medical devices. This has resulted in increased health care expenditures and health care-generated waste and pollution, with associated public health damage. It has also caused the supply chain to be vulnerable to disruption and demand fluctuations. Transformation of the medical device industry to a more circular economy would advance the goal of providing increasingly complex care in a low-emissions future. Barriers to circularity include perceptions regarding infection prevention, behaviors of device consumers and manufacturers, and regulatory structures that encourage the proliferation of disposable medical devices. Complementary policy- and market-driven solutions are needed to encourage systemic transformation.

To the Editor: The global coronavirus disease (COVID-19) pandemic has seen a significant increase in the use of preprint services to enable the widespread dissemination of research findings (1). However, whether such facilities influence practice change is currently unknown. Here, we describe the impact of the preprint release and eventual publication of the RECOVERY (Randomised Evaluation of COVID-19 Therapy) trial (2) on corticosteroid use in clinical practice in Australian ICUs. The RECOVERY trial tested the efficacy of dexamethasone (6 mg by mouth or intravenously for up to 10 d) in hospitalized patients with clinically suspected or confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and demonstrated a reduction in 28-day mortality, particularly in those receiving either mechanical ventilation or oxygen. Before these results, the Australian and New Zealand Intensive Care Society COVID-19 guidelines recommended against the routine use of corticosteroids (3).

Significant concern exists regarding the risk of transmission of severe acute respiratory syndrome coronavirus 2 (SARSCov-2) to health care workers during aerosol generating procedures.The risk of viral transmission to health care workers during tracheostomy insertion is unknown.

ObjectiveIdentify the views of healthcare leaders towards public healthcare’s carbon footprint; the importance or not of healthcare energy supply and sources and; the perceived key barriers for Victorian health care to show leadership on renewable energy sources and supply. MethodsSelf-administered questionnaire (10 Likert scale, two open-ended questions) among 24 Victorian Health Chief Executive Officers (CEOs). Responses were anonymous. Descriptive analysis was conducted. ResultsOverall, 13/24 (54%) of CEOs responded. A majority (11/13) agreed that climate change is causing real and accelerating harm to health and the environment, with impacts on patients, staff and services a current issue. One hundred percent (13/13) saw leadership by the public healthcare sector on environmental sustainability as an important responsibility (strongly agreed, 9/13 (69%); agreed, 4/13 (31%)), with most CEOs supporting their institution increasing the amount of renewable electricity supply over-and-above grid levels (strongly agreed, 3/13 (23%); agreed, 9/13 (69%)). However, support for renewable electricity was, for the most part, aspirational and not perceived as a current priority. The key perceived barriers to increasing renewable electricity supply were Health Purchasing Victoria contract and financial constraints. ConclusionsHealth care itself has a carbon footprint. Public healthcare CEOs are supportive of their institutions increasing use of renewable electricity supply, yet perceived barriers regarding inflexible and poorly transparent purchasing contracts and financial cost exist. What is known about the topic?Australian health care contributes ~7 percent to Australia’s total carbon emissions, with hospital energy consumption (coal-generated electricity and natural/fossil gas) a large majority. An executive level champion is a consistent factor across health services that are taking the lead on environmental sustainability. What does this paper add?Our research is original in understanding the views of Victorian public healthcare CEOs on climate change, renewable energy supply and key barriers to increasing uptake. A majority of public healthcare CEOs see energy choices as an important issue for their patients, staff and institution, and that greater leadership should be shown by health care in light of the urgency required to address greenhouse gas emissions. However, support for renewable electricity was, for the most part, aspirational, with specific barriers identified across the healthcare network. What are the implications for practitioners?This research provides information that can inform a pathway to healthcare decarbonisation via sector-wide action.

To quantify aerosol generation from respiratory interventions and the effectiveness of their removal by a personal ventilation hood.Determination of the aerosol particle generation (in a single, healthy volunteer in a clean room) associated with breathing, speaking, wet coughing, oxygen (OAerosol generation was measured with two particle sizer and counter devices, focusing on aerosols 0.5-5 μm (human-generated aerosols), with and without the hood. An increase from baseline of less than 0.3 particles per mL was considered a low level of generation.Comparisons of aerosol generation between different respiratory interventions. Effectiveness of aerosol reduction by a personal ventilation hood.Results for the 0.5-5 μm aerosol range. Quiet breathing and talking demonstrated very low increase in aerosols (0.1 particles/mL). Aerosol generation was low for wet coughing (0.1 particles/mL), OIn this human volunteer study, the administration of O

Background Approaches to routine diagnostic testing in the intensive care unit include time-scheduled testing and targeted testing. Blood tests and chest radiographs requested on a routine, time-scheduled basis may reduce the risk of missing important findings. Targeted testing, considering individual patient needs, may reduce unnecessary testing, wasted clinician time, and costs. However, existing evidence of targeted testing interventions is generally of low quality, and the optimal testing approach is uncertain. Objectives The aim of the study was to describe the development of an intervention to reduce unnecessary diagnostic test ordering by clinicians working in intensive care, with the aim of informing the design of a pivotal clinical trial. Methods The Capability, Opportunity, Motivation-Behaviour model was used as a theoretical framework for change. The intervention components were informed by systematically identifying, assessing, and classifying targeted testing interventions in behavioural terms. Feedback from intensive care clinicians and patients was sought using surveys and a consumer reference group. Results The mean percentage of routine tests considered unnecessary by 201 intensive care clinicians was 33 (standard deviation = 16). When presented with a statement of the pros and cons for targeted versus liberal testing (n = 154), 93 (60%) consumer survey respondents preferred a more liberal approach, 33 (21%) preferred a more restrictive approach, and 28 (18%) were unsure. There were 24 behavioural interventions identified and incorporated into the final intervention. This had five major components: (i) a management committee to acquire, disseminate, and coordinate intervention-related information, (ii) a targeted testing guideline for sites, (iii) educational material for sites, (iv) site medical and nursing champions, and (v) site audit and feedback. Conclusions Although surveyed intensive care clinicians report substantial unnecessary routine diagnostic testing, on the basis of currently available evidence, consumers prefer a more liberal approach. This feedback, and a framework to identify behavioural interventions, has been used to inform the design of a proposed targeted testing clinical trial.

Summary The detrimental health effects of climate change continue to increase. Although health systems respond to this disease burden, healthcare itself pollutes the atmosphere, land, and waterways. We surveyed the ‘state of the art’ environmental sustainability research within anaesthesia and critical care, addressing why it matters, what is known, and ideas for future work. Focus is placed upon the atmospheric chemistry of the anaesthetic gases, recent work clarifying their relative global warming potentials, and progress in waste anaesthetic gas treatment. Life cycle assessment (LCA; i.e. ‘cradle to grave’ analysis) is introduced as the definitive method used to compare and contrast ecological footprints of products, processes, and systems. The number of LCAs within medicine has gone from rare to an established body of knowledge in the past decade that can inform doctors of the relative ecological merits of different techniques. LCAs with practical outcomes are explored, such as the carbon footprint of reusable vs single-use anaesthetic devices (e.g. drug trays, laryngoscope blades, and handles), and the carbon footprint of treating an ICU patient with septic shock. Avoid, reduce, reuse, recycle, and reprocess are then explored. Moving beyond routine clinical care, the vital influences that the source of energy (renewables vs fossil fuels) and energy efficiency have in healthcare's ecological footprint are highlighted. Discussion of the integral roles of research translation, education, and advocacy in driving the perioperative and critical care environmental sustainability agenda completes this review.

Background: A multidisciplinary collaboration investigated the world's largest, most catastrophic epidemic thunderstorm asthma event that took place in Melbourne, Australia, on Nov 21, 2016, to inform mechanisms and preventive strategies. Methods: Meteorological and airborne pollen data, satellite-derived vegetation index, ambulance callouts, emergency department presentations, and data on hospital admissions for Nov 21, 2016, as well as leading up to and following the event were collected between Nov 21, 2016, and March 31, 2017, and analysed. We contacted patients who presented during the epidemic thunderstorm asthma event at eight metropolitan health services (each including up to three hospitals) via telephone questionnaire to determine patient characteristics, and investigated outcomes of intensive care unit (ICU) admissions. Findings: Grass pollen concentrations on Nov 21, 2016, were extremely high (>100 grains/m 3 ). At 1800 AEDT, a gust front crossed Melbourne, plunging temperatures 10°C, raising humidity above 70%, and concentrating particulate matter. Within 30 h, there were 3365 (672%) excess respiratory-related presentations to emergency departments, and 476 (992%) excess asthma-related admissions to hospital, especially individuals of Indian or Sri Lankan birth (10% vs 1%, p

Importance It is unclear whether vitamin C, hydrocortisone, and thiamine are more effective than hydrocortisone alone in expediting resolution of septic shock. Objective To determine whether the combination of vitamin C, hydrocortisone, and thiamine, compared with hydrocortisone alone, improves the duration of time alive and free of vasopressor administration in patients with septic shock. Design, Setting, and Participants Multicenter, open-label, randomized clinical trial conducted in 10 intensive care units in Australia, New Zealand, and Brazil that recruited 216 patients fulfilling the Sepsis-3 definition of septic shock. The first patient was enrolled on May 8, 2018, and the last on July 9, 2019. The final date of follow-up was October 6, 2019. Interventions Patients were randomized to the intervention group (n = 109), consisting of intravenous vitamin C (1.5 g every 6 hours), hydrocortisone (50 mg every 6 hours), and thiamine (200 mg every 12 hours), or to the control group (n = 107), consisting of intravenous hydrocortisone (50 mg every 6 hours) alone until shock resolution or up to 10 days. Main Outcomes and Measures The primary trial outcome was duration of time alive and free of vasopressor administration up to day 7. Ten secondary outcomes were prespecified, including 90-day mortality. Results Among 216 patients who were randomized, 211 provided consent and completed the primary outcome measurement (mean age, 61.7 years [SD, 15.0]; 133 men [63%]). Time alive and vasopressor free up to day 7 was 122.1 hours (interquartile range [IQR], 76.3-145.4 hours) in the intervention group and 124.6 hours (IQR, 82.1-147.0 hours) in the control group; the median of all paired differences was –0.6 hours (95% CI, –8.3 to 7.2 hours;P = .83). Of 10 prespecified secondary outcomes, 9 showed no statistically significant difference. Ninety-day mortality was 30/105 (28.6%) in the intervention group and 25/102 (24.5%) in the control group (hazard ratio, 1.18; 95% CI, 0.69-2.00). No serious adverse events were reported. Conclusions and Relevance In patients with septic shock, treatment with intravenous vitamin C, hydrocortisone, and thiamine, compared with intravenous hydrocortisone alone, did not significantly improve the duration of time alive and free of vasopressor administration over 7 days. The finding suggests that treatment with intravenous vitamin C, hydrocortisone, and thiamine does not lead to a more rapid resolution of septic shock compared with intravenous hydrocortisone alone. Trial Registration ClinicalTrials.gov Identifier:NCT03333278

Strategies to reduce the adverse environmental costs of anaesthesia include choice of agent and fresh gas flows. The current preferences of Australian and New Zealand anaesthetists are unknown. We conducted a survey of Australian and New Zealand anaesthetists to determine the use of volatiles, nitrous oxide and intravenous anaesthesia, lowest fresh gas flow rates, automated end-tidal volatile control, and the rationales for these choices. The survey was answered by 359/1000 (36%), although not all questions and multiple responses within single questions were answered by all respondents. Sevoflurane was preferred by 246/342 (72%, 95% confidence interval (CI) 67%–77%), followed by propofol, 54/340 (16%, 95% CI 12%–20%), desflurane 39/339 (12%, 95% CI 8%–16%) and isoflurane 3/338(1%, 95% CI 0–3%). When asked about all anaesthetics, low-risk clinical profile was the most common reason given for using sevoflurane (129/301 (43%, 95% CI 37%–49%)), reduced postoperative nausea for propofol (297/318 (93%, 95% CI 90%–96%)) and faster induction/awakening times for desflurane (46/313 (79%, 95% CI 74%–83%)). Two-thirds (226/340 (66%, 95% CI 61%–71%)) of respondents used nitrous oxide in 0–20% of general anaesthetics. Low fresh gas flow rates for sevoflurane were used by 310/333 (93%, 95% CI 90%–95%) and for 262/268 (98%, 95% CI 95%–99%) for desflurane. Automated end-tidal control was used by 196/333 (59%, 95% CI 53%–64%). The majority of respondents (>70%) preferred sevoflurane at low flows. These data allow anaesthetists to consider further whether changes are required to the choices of anaesthetic agents for environmental, financial, or any other reasons.

Background Although propofol is widely used for sedation in intensive care units around Australia, evaluation of bedside nursing practices of the administration of propofol have been limited. We investigated whether there was a discrepancy between the amount of propofol delivered by the infusion pump and that recorded electronically and consequently patient exposure to avoidable harms. Aims The aim of this research was to compare the total amount of propofol administered to intensive care patients via a programmable infusion pump with that documented in the electronic medical record (EMR). Secondary objectives were to ascertain the percentage of 1) patients exposed to a propofol dose greater than recommended and 2) daily energy requirements administered as propofol infusion. Methods This was a prospective, observational study of total propofol delivered to 50 patients in a 14-bed metropolitan, Australian intensive care unit. Infusion pump data and entries from the EMR were collated. Results Propofol sedation was administered for a median 18 (interquartile range: 14–47) hours with median total propofol 3025 mg (interquartile range: 1840–7755 mg) by pump and 3250 mg (interquartile range: 1915–6960 mg) by EMR, i.e. 1.9 (interquartile range: 1.3–2.3) mg/kg/hour by pump (correlation coefficient = 0.99). The total bolus propofol documented in the EMR was a median 330 mg (interquartile range: −838 to −124) less than the pump amount. Nineteen (38%) patients had no EMR-documented propofol boluses yet had received at least one bolus via the pump. In two of 50 (4%) patients, the pump propofol infusion dose was above the recommended maximum safe dose of 4 mg/kg/h. Conclusion In this cohort of patients, the bolus administration of propofol was frequently not documented, potentially placing some patients at risk of drug-related toxicity. Further research to develop and implement strategies to improve the documentation of propofol administration is indicated.

The setting of tidal volume (VWe performed a multicentre, prospective, observational study. We collected clinical, ventilatory and arterial blood gas data twice daily for 7 days. We performed subgroup analysis by sex and assessment of arterial partial pressure of carbon dioxide (PaCOWe recorded 453 observational sets in 123 patients across seven ICUs. The most commonly selected initial VIn adults without ARDS undergoing CMV in Australian ICUs, the initial V

Objectives Steam sterilization in hospitals is an energy and water intensive process. Our aim was to identify opportunities to improve electricity and water use. The objectives were to find: the time sterilizers spent active, idle and off; the variability in sterilizer use with the time of day and day of the week; and opportunities to switch off sterilizers instead of idling when no loads were waiting, and the resultant electricity and water savings. Methods Analyses of routine data for one year of the activity of the four steam sterilizers in one hospital in Melbourne, Australia. We examined active sterilizer cycles, routine sterilizer switch-offs, and when sterilizers were active, idle and off. Several switch-off strategies were examined to identify electricity and water savings: switch off idle sterilizers when no loads are waiting and switch off one sterilizer after 10:00 h and a second sterilizer after midnight on all days. Results Sterilizers were active for 13,430 (38%) sterilizer–hours, off for 4822 (14%) sterilizer–hours, and idle for 16,788 (48%) sterilizer–hours. All four sterilizers were simultaneously active 9% of the time, and two or more sterilizers were idle for 69% of the time. A sterilizer was idle for two hours or less 13% of the time and idle for more than 2 h 87% of the time. A strategy to switch off idle sterilizers would reduce electricity use by 66 MWh and water use by 1004 kl per year, saving 26% electricity use and 13% of water use, resulting in financial savings of AUD$13,867 (UK£6,517) and a reduction in 79 tonnes of CO2 emissions per year. An alternative switch-off strategy of one sterilizer from 10:00 h onwards and a second from midnight would have saved 30 MWh and 456 kl of water. Conclusions The methodology used of how hospital sterilizer use could be improved could be applied to all hospitals and more broadly to other equipment used in hospitals.

To obtain an accurate estimate of smoking prevalence and smoking cessation support practices, including nicotine replacement therapy (NRT), in Australian and New Zealand intensive care units (ICUs).Cross-sectional, observational study using data obtained from adult ICUs participating in the Australian and New Zealand Intensive Care Society Clinical Trials Group Point Prevalence Program in 2016.Prevalence and intensity of current smoking, baseline characteristics of smokers in comparison with non-smokers and frequency of NRT use while admitted to the ICU.Smoking data were present for 551 of 671 adult ICU patients from 47 ICUs on 2 study days in 2016. Of these 551 patients, 112 were current smokers (20.3%; 95% CI, 17.0-23.9%). No significant differences in severity of illness or mortality were observed between smokers and non-smokers. NRT was prescribed to 30/112 smokers (26.8%), and in 28 of those 30 patients (93%) it was administered via nicotine patch alone. Routine prescribing of NRT was practised in 28/47 ICUs (60%), and 24/47 ICUs (51%) had formal protocols or guidelines in place related to supporting smoking cessation.The prevalence of smoking in Australian and New Zealand ICUs patients is high. Over half of participating ICUs reported the routine prescription of NRT despite uncertainty regarding the practice. Further research evaluating the safety and efficacy of NRT is required.

We sought to estimate the proportion of patients admitted to a metropolitan intensive care unit (ICU) who were current smokers, and the relationships between ICU survivors who smoked and smoking cessation and/or reduction six months post–ICU discharge. We conducted a prospective cohort study at a metropolitan level III ICU in Melbourne, Victoria. One hundred consecutive patients who met the inclusion criteria were included in the study. Inclusion criteria consisted of patients who were smokers at time of ICU admission, had an ICU length of stay greater than one day, survived to ICU discharge, and provided written informed consent. A purpose-designed questionnaire which included the Fagerstrom test for nicotine dependence and evaluation of patients’ attitude towards smoking cessation was completed by participants following ICU discharge and prior to hospital discharge. Participants were re-interviewed over the phone at six months post–ICU discharge. Of the 1,062 patients admitted to ICU, 253 (23%) were current smokers and 100 were enrolled. Six months post–ICU discharge, 28 (33%) of the 86 participants who were alive and contactable had quit smoking and 35 (41%) had reduced smoking. The median number of reported cigarettes smoked per day reduced by 40%. Participants who initially believed their ICU admission was smoking-related were more likely to have quit six months post–ICU discharge (odds ratio 2.98; 95% confidence intervals 1.07, 8.26; P=0.036). Six months post–ICU discharge, 63/86 (74%) of participants had quit or reduced their smoking. Further research into targeted smoking cessation counselling for ICU survivors is indicated.

Summary Background Carbon footprints stemming from health care have been found to be variable, from 3% of the total national CO 2 equivalent (CO 2 e) emissions in England to 10% of the national CO 2 e emissions in the USA. We aimed to measure the carbon footprint of Australia's health-care system. Methods We did an observational economic input–output lifecycle assessment of Australia's health-care system. All expenditure data were obtained from the 15 sectors of the Australian Institute of Health and Welfare for the financial year 2014–15. The Australian Industrial Ecology Virtual Laboratory (IELab) data were used to obtain CO 2 e emissions per AUS$ spent on health care. Findings In 2014–15 Australia spent $161·6 billion on health care that led to CO 2 e emissions of about 35 772 (68% CI 25 398–46 146) kilotonnes. Australia's total CO 2 e emissions in 2014–15 were 494 930 kilotonnes, thus health care represented 35 772 (7%) of 494 930 kilotonnes total CO 2 e emissions in Australia. The five most important sectors within health care in decreasing order of total CO 2 e emissions were: public hospitals (12 295 [34%] of 35 772 kilotonnes CO 2 e), private hospitals (3635 kilotonnes [10%]), other medications (3347 kilotonnes [9%]), benefit-paid drugs (3257 kilotonnes [9%]), and capital expenditure for buildings (2776 kilotonnes [8%]). Interpretation The carbon footprint attributed to health care was 7% of Australia's total; with hospitals and pharmaceuticals the major contributors. We quantified Australian carbon footprint attributed to health care and identified health-care sectors that could be ameliorated. Our results suggest the need for carbon-efficient procedures, including greater public health measures, to lower the impact of health-care services on the environment. Funding None.

Background An innovative approach to choosing hospital equipment is to consider the environmental costs in addition to other costs and benefits. Methods We used life cycle assessment to model the environmental and financial costs of different scenarios of replacing reusable anaesthetic equipment with single-use variants. The primary environmental costs were CO2 emissions (in CO2 equivalents) and water use (in litres). We compared energy source mixes between Australia, the UK/Europe, and the USA. Results For an Australian hospital with six operating rooms, the annual financial cost of converting from single-use equipment to reusable anaesthetic equipment would be an AUD$32 033 (£19 220), 46% decrease. In Australia, converting from single-use to reusable equipment would result in an increase of CO2 emissions from 5095 (95% CI: 4614–5658) to 5575 kg CO2 eq (95% CI: 5542–5608), a 480 kg CO2 eq (9%) increase. Using the UK/European power mix, converting from single-use (5575 kg CO2 eq) to reusable anaesthetic equipment (802 kg CO2 eq) would result in an 84% reduction (4873 kg CO2 eq) in CO2 emissions, whilst in the USA converting to reusables would have led to a 2427 kg CO2 eq (48%) reduction. In Australia, converting from single-use to reusable equipment would more than double water use from 34.4 to 90.6 kilolitres. Conclusions For an Australian hospital with six operating rooms, converting from single-use to reusable anaesthetic equipment saved more than AUD$30 000 (£18 000) per annum, but increased the CO2 emissions by almost 10%. The CO2 offset is highly dependent on the power source mix, while water consumption is greater for reusable equipment.

In the presence of single-use airway filters, we quantified anaesthetic circuit aerobic microbial contamination rates when changed every 24 h, 48 h and 7 days. Microbiological samples were taken from the interior of 305 anaesthetic breathing circuits over a 15-month period (3197 operations). There was no significant difference in the proportion of contaminated circuits when changed every 24 h (57/105 (54%, 95% CI 45-64%)) compared with 48 h (43/100 (43%, 95% CI 33-53%, p = 0.12)) and up to 7 days (46/100 (46%, 95% CI 36-56%, p = 0.26)). Median bacterial counts were not increased at 48 h or 7 days provided circuits were routinely emptied of condensate. Annual savings for one hospital (six operating theatres) were $AU 5219 (£3079, €3654, $US 4846) and a 57% decrease in anaesthesia circuit steriliser loads associated with a yearly saving of 2760 kWh of electricity and 48 000 l of water. Our findings suggest that extended circuit use from 24 h up to 7 days does not significantly increase bacterial contamination, and is associated with labour, energy, water and financial savings.

Background Lack of compliance with drug libraries among users of smart infusion pumps undermines the efforts to prevent intravenous medication errors. There are little data on drug library use in Australian clinical practice and the barriers to compliance and effective use remain uncertain. Aim To evaluate the use of a smart infusion pump's drug libraries and to identify barriers to effective drug library use. Method Prescription and programming details of the infusions administered via Alaris IV pumps at a health service were audited. Data were used to assess compliance with and use of the drug libraries. In the event of non-compliance or incorrect use of a drug library, a consented interview was conducted with the nurse to identify barriers. Results Of the 86% (95%CI 83–89) of infusions administered via a drug library, 11% (95%CI 9.1–14) were programmed incorrectly. Interviews with nurses revealed several reasons for non-compliance, e.g. difficulty in using smart infusion pump technology, composition of the drug library. Incorrect drug library use was mainly attributed to failure to check programming during change of nursing shift, change of clinical area or change to a new fluid bag. Conclusion Despite high compliance with correct drug library use, 11% of infusions were programmed incorrectly due to incorrect selection of a drug library or therapy or both. The interviews revealed concerns with understanding smart pump technology and deficiencies in routine checks of drug library programming.

Economic and environmental sustainability are essential to maintaining delivery of high quality healthcare. Numerous medical innovations in recent times demonstrate that modern cardiovascular care is in quick and constant flux. Examples are the novel minimally-invasive interventions, improved disease management in heart failure, innovative methods in atrial fibrillation ablation or the personalized medicine approach in cardiomyopathies. Healthcare's predilection, however, for a single use oil-based plastics and metalware are unsustainable in the long run (even considering a 50 year time frame, let alone 1000 years). Sustainability is not an isolated competency of clinical practice, but instead transcends such seemingly disparate fields such as: finance, environment, security, resilience, staffing, efficiency, effectiveness, patient centred care and business ethics. Healthcare providers tend to be isolated in domains within hospitals such as the paediatric catherization (cath) laboratory (lab) and the operating room, with a limited understanding of the full process, complexity and broader implications of “what we do” daily and How these practices impact the environment. Consider the following simple “sustainability” questions: What are the financial costs of a routine angiogram for a child with Tetralogy of Fallot? How much waste per day is produced by the cath lab? Is it possible to use reusable instead of single use medical devices? In this paper we explore the: (a) incremental sustainability changes; (b) opportunities and barriers for sustainability initiatives within the paediatric cath lab; (c) discuss the transformational changes aimed at broader concerns about “unsustainable" cardiovascular care”; and, (d) provide a roadmap for sustainability education, training and research. Sustainable solutions must enable pediatric cardiovascular clinicians to not to make sound clinical decisions and provide safer procedures, but also address the growing economic and environmental challenges faced by today's healthcare systems.

There is little known about recyclable intensive care unit waste. We tested the hypotheses that the intensive care unit produces a small proportion (10%) of hospital waste, that much waste (30%) is recyclable and that there is little (10%) cross-contamination of non-infectious with infectious waste. For seven consecutive days in an Australian 10-bedded intensive care unit, we prospectively sorted all waste. The total intensive care unit waste for the week was 540 kg, representing 5% of hospital waste. Of the 401 kg of intensive care unit general waste, recyclables were 230 kg (57%; 95% CI 53-61%), mainly plastics, cardboard and paper. There were 0.4 kg of infectious cross-contamination in the 401 kg of general waste. Intensive care unit waste was a small proportion of all hospital waste. However, there was minimal infectious waste cross-contamination and almost 60% of intensive care unit general waste could be recycled with appropriate safeguards, education and training.

Objective: To describe the quality of postoperative documentation of vital signs and of medical and nursing review and to identify the patient and hospital factors associated with incomplete documentation. Design, setting and participants: Retrospective audit of medical records of 211 adult patients following major surgery in five Australian hospitals, August 2003 – July 2005. Main outcome measures: Proportion of patients with complete documentation of medical review (each day) and nursing review and vital signs (heart rate, blood pressure, respiratory rate, temperature and oxygen saturation) (each nursing shift), and the proportion of available opportunities for medical and nursing review where documentation was incomplete. Univariate and multivariate odds ratios for the association between incomplete documentation and hospital and patient factors. Results: During the first 3 postoperative ward days, 17% of medical records had complete documentation of vital signs and medical and nursing review. During the first 7 postoperative ward days, nursing review was undocumented for 5.6% of available shifts and medical review for 14.9% of available days. Respiratory rate was the most commonly undocumented observation (15.4% undocumented). Certain hospitals were significantly associated with incomplete documentation. Vital signs were more commonly undocumented in patients without epidural or patient-controlled (PC) analgesia, during evening nursing shifts, and during successive postoperative ward days. Nursing review was more commonly undocumented in the evening and for patients without epidural or PC analgesia. Medical review was more commonly undocumented on weekends. Conclusion: Hospital and patient factors are associated with incomplete

Objective The aim of the present study was to quantify hospital steam steriliser resource consumption to provide baseline environmental data and identify possible efficiency gains. We sought to find the amount of steriliser electricity and water used for active cycles and for idling (standby), and the relationship between the electricity and water consumption and the mass and type of items sterilised. Methods We logged a hospital steam steriliser’s electricity and water meters every 5 min for up to 1 year. We obtained details of all active cycles (standard 134°C and accessory or ‘test’ cycles), recording item masses and types. Relationships were investigated for both the weight and type of items sterilised with electricity and water consumption. Results Over 304 days there were 2173 active cycles, including 1343 standard 134°C cycles that had an average load mass of 21.2 kg, with 32% of cycles

Much waste arises from operating rooms (ORs). We estimated the practical and financial feasibility of an OR recycling program, weighing all waste from 6 ORs in Melbourne, Australia. Over 1 week, 237 operations produced 1265 kg in total: general waste 570 kg (45%), infectious waste 410 kg (32%), and recyclables 285 kg (23%). The achieved recycling had no infectious contamination. The achieved recycling/potential recycling rate was 285 kg/517 kg (55%). The average waste disposal costs were similar for general waste and recycling. OR recycling rates of 20%-25% total waste were achievable without compromising infection control or financial constraints.

The provision of health care has significant direct environmental effects such as energy and water use and waste production, and indirect effects, including manufacturing and transport of drugs and equipment. Recycling of hospital waste is one strategy to reduce waste disposed of as landfill, preserve resources, reduce greenhouse gas emissions, and potentially remain fiscally responsible. We began an intensive care unit recycling program, because a significant proportion of ICU waste was known to be recyclable.To determine the weight and proportion of ICU waste recycled, the proportion of incorrect waste disposal (including infectious waste contamination), the opportunity for further recycling and the financial effects of the recycling program.We weighed all waste and recyclables from an 11-bed ICU in an Australian metropolitan hospital for 7 non-consecutive days. As part of routine care, ICU waste was separated into general, infectious and recycling streams. Recycling streams were paper and cardboard, three plastics streams (polypropylene, mixed plastics and polyvinylchloride [PVC]) and commingled waste (steel, aluminium and some plastics). ICU waste from the waste and recycling bins was sorted into those five recycling streams, general waste and infectious waste. After sorting, the waste was weighed and examined. Recycling was classified as achieved (actual), potential and total. Potential recycling was defined as being acceptable to hospital protocol and local recycling programs. Direct and indirect financial costs, excluding labour, were examined.During the 7-day period, the total ICU waste was 505 kg: general waste, 222 kg (44%); infectious waste, 138 kg (27%); potentially recyclable waste, 145 kg (28%). Of the potentially recyclable waste, 70 kg (49%) was actually recycled (14% of the total ICU waste). In the infectious waste bins, 82% was truly infectious. There was no infectious contamination of the recycling streams. The PVC waste was 37% contaminated (primarily by other plastics), but there was less than 1% contamination of other recycling streams. The estimated cost of the recycling program was about an additional $1000/year.In our 11-bed ICU, we recycled 14% of the total waste produced over 7-days, which was nearly half of the potentially recyclable waste. There was no infectious contamination of recyclables and minimal contamination with other waste streams, except for the PVC plastic. The estimated annual cost of the recycling program was $1000, reflecting the greater cost of disposal of some recyclables (paper and cardboard v most plastic types).

To examine self-reported treatment preferences among Australasian consultant intensivists for intensive care-acquired hypernatraemia (IAH).We used a web-based survey with 10 questions about the management of IAH.We measured number of respondents and response rate, IAH treatment methods, thresholds and the reasons for these.There were 156 survey respondents, of whom 137 were consultant intensivists, representing a response rate of 31%. Ninety-three percent of responding clinicians (95% CI, 87%-96%) used intravenous fluid (49%; 95% CI, 40%-57%) or enteral nutrition changes (44%; 95% CI, 36%-53%) as their first choice of treatment. As alternative therapies, respondents reported using thiazides (22%; 95% CI, 16%-30%), aldosterone antagonists (20%; 95% CI, 14%-28%) and renal replacement therapy (14%; 95% CI, 9%-21%) less commonly.There is a wide variety of treatments in use for IAH. Most clinicians initiate treatment at a level greater than the level that is independently associated with increased mortality in the literature.1 Initial treatment is equally divided between changes in intravenous fluid and changes in enteral nutrition.

Objectives Hospitals are significant contributors to natural resource depletion and environmental change. Our objective was to establish the extent to which hospital environmental sustainability has been studied and the key issues that emerge for policy, practice and research. Methods The PubMed, Engineering Village, Cochrane and King's Fund databases were searched for articles relating to hospital environmental sustainability published in English between 1 January 1990 and 1 October 2013. Further studies were found by review of reference lists. One hundred ninety-three relevant articles were found and 76 were selected for inclusion in the review. Results Common research themes were identified: hospital design, direct energy consumption, water, procurement, waste, travel and psychology and behaviour. Some countries (particularly the United Kingdom) have begun to invest systematically in understanding the environmental effects of hospitals. We found large variability in the extent of the evidence base according to topic. Research regarding the architectural fabric of hospital buildings is at a relatively mature stage. Similarly, there is a developed research base regarding devices and technologies used within hospitals to reduce the environmental effects of direct hospital energy and water use. Less is known about the clinical, psychological and social factors that influence how health care professionals use resources, travel to/from hospital, and interact with the buildings and technologies available. A significant part of the environmental footprint of hospitals relates to clinical practice, e.g. decisions regarding the use of pharmaceuticals and medical devices. Medical ‘cradle to grave’ life cycle assessment studies have been published to understand the full financial and environmental costs of hospital activities. The effects of preventive or demand management measures which avoid unnecessary hospital procedures are likely to be much greater than incremental changes to how hospital procedures are performed. Conclusions There remain significant gaps in the evidence base on hospital sustainability. Assessments of environmental impacts and natural resource use are beginning to be produced, both at the level of individual hospitals and at the health system level. These are an important start, but in many areas do not yet provide sufficiently detailed information to guide decision-making. There are many areas where the interests of patients and the environment coincide, but others where tensions exist. Rising resource costs and climate change mitigation measures are likely to create an increasing stimulus for research on hospital sustainability. Such research will benefit from inter-disciplinary coordination across research funders and countries.

We present the first six cases of H1N1 influenza 09 (confirmed by a polymerase chain reaction test from nasopharyngeal swabs) in patients requiring admission to intensive care in Australia (in three hospitals in the north-western suburbs of Melbourne). These cases highlight the small but significant risk of life-threatening respiratory failure associated with H1N1 influenza 09 infection.

The relationship between English proficiency and health care outcomes in intensive care has rarely been examined. This study aimed to determine whether being a non-English speaker would predict mortality in a critical care setting. Secondary end points were intensive care unit (ICU) and hospital length of stay.This is a single-center, retrospective, cohort study of admissions from January 1, 2000 until December 31, 2011 in a tertiary level intensive care setting in Melbourne, Australia. All admissions during the study period were included. Patients without language data were excluded. Of those with multiple admissions, only the first was included. Analysis of 20082 ICU admissions was undertaken, of which 19059 (94.9%) were English speakers.After adjusting for confounding variables (age, severity of illness, diagnostic group, year of admission, and socioeconomic status), English-speaking status was independently associated with an increased risk of death (odds ratio, 1.91; 95% confidence interval 1.46-2.49; P.001). There was no difference in ICU length of stay between groups. Hospital length of stay was shorter for English speakers.Contrary to expectations, this large single-center study shows a consistent relationship between non-English-speaking status and increased survival after admission to ICU.

OBJECTIVE: To examine the environmental life cycle from poppy farming through to production of 100 mg in 100 mL of intravenous morphine (standard infusion bag). DESIGN: 'Cradle-to-grave' process-based life cycle assessment (observational). SETTINGS: Australian opium poppy farms, and facilities for pelletising, manufacturing morphine, and sterilising and packaging bags of morphine. MAIN OUTCOME MEASURES: The environmental effects (eg, CO2 equivalent ('CO2 e') emissions and water use) of producing 100 mg of morphine. All aspects of morphine production from poppy farming, pelletising, bulk morphine manufacture through to final formulation. Industry-sourced and inventory-sourced databases were used for most inputs. RESULTS: Morphine sulfate (100 mg in 100 mL) had a climate change effect of 204 g CO2 e (95% CI 189 to 280 g CO2 e), approximating the CO2 e emissions of driving an average car 1 km. Water use was 7.8 L (95% CI 6.7- to 9.0 L), primarily stemming from farming (6.7 L). All other environmental effects were minor and several orders of magnitude less than CO2 e emissions and water use. Almost 90% of CO2 e emissions occurred during the final stages of 100 mg of morphine manufacture. Morphine's packaging contributed 95 g CO2 e, which accounted for 46% of the total CO2 e (95% CI 82 to 155 g CO2 e). Mixing, filling and sterilisation of 100 mg morphine bags added a further 86 g CO2 e, which accounted for 42% (95% CI 80 to 92 g CO2 e). Poppy farming (6 g CO2 e, 3%), pelletising and manufacturing (18 g CO2 e, 9%) made smaller contributions to CO2 emissions. CONCLUSIONS: The environmental effects of growing opium poppies and manufacturing bulk morphine were small. The final stages of morphine production, particularly sterilisation and packaging, contributed to almost 90% of morphine's carbon footprint. Focused measures to improve the energy efficiency and sources for drug sterilisation and packaging could be explored as these are relevant to all drugs. Comparisons of the environmental effects of the production of other drugs and between oral and intravenous preparations are required.

BACKGROUND: For most items used in operating rooms, it is unclear whether reusable items are environmentally and financially advantageous in comparison with single-use variants. We examined the life cycles of reusable and single-use central venous catheter kits used to aid the insertion of single-use, central venous catheters in operating rooms. We did not examine the actual disposable catheter sets themselves. We assessed the entire financial and environmental costs for the kits, including the influence of the energy source used for sterilization. METHODS: For the reusable central venous catheter kit, we performed a "time-in-motion" study to determine the labor costs and measured the energy and water consumption for cleaning and sterilization at Western Health, Melbourne, Australia. For the majority of the inputs for the single-use kit, we relied upon industry and inventory-sourced databases. We modeled the life cycles of the reusable and single-use central venous catheter kits with Monte Carlo analysis. RESULTS: Inclusive of labor, the reusable central venous catheter insertion kits cost $6.35 Australian ($A) (95% confidence interval [CI], $A5.89 to $A6.86), and the single-use kits cost $A8.65. For the reusable kit, CO(2) emissions were 1211 g (95% CI, 1099 to 1323 g) and for the single-use kit 407 g (95% CI, 379 to 442 g). Water use was 27.7 L (95% CI, 27.0 to 28.6 l) for the reusable kit and 2.5 L (95% CI, 2.1 to 2.9 l) for the single-use kit. For the reusable kit, sterilization had the greatest environmental cost, and for the single-use kit, the manufacture of plastic and metal components had the largest environmental costs. Different sources of electricity to make the reusable kits patient-ready again affected the CO(2) emissions: electricity from hospital gas cogeneration resulted in 436 g CO(2) (95% CI, 410 to 473 g CO(2)), from the United States electricity grid 764 g CO(2) (95% CI, 509 to 1174 g CO(2)), and from the European electricity grid 572 g (95% CI, 470 to 713 g CO(2)). CONCLUSIONS: Inclusive of labor, the reusable central venous catheter insertion kits were less expensive than were the single-use kits. For our hospital, which uses brown coal-sourced electricity, the environmental costs of the reusable kit were considerably greater than those of the single-use kit. Efforts to reduce the environmental footprint of reusable items should be directed towards decreasing the water and energy consumed in cleaning and sterilization. The source of hospital electricity significantly alters the relative environmental effects of reusable items.

The key aspects and features of the National Greenhouse and Energy Reporting (NGER) Act 2007 enacted by the Australian Government in response to climate change are discussed. The different steps that need to be taken by hospitals in order to meet the hospital accreditation standards are highlighted.

Hypernatraemia may develop during intravenous infusion of frusemide. Spironolactone is an aldosterone antagonist that promotes natriuresis and may attenuate such hypernatraemia, but its effect in this setting has not been previously studied.To assess whether the administration of spironolactone to ventilated patients receiving a frusemide infusion attenuates the increase in serum sodium concentration.Randomised, double-blind, placebo-controlled trial (January 2005 to December 2006).20 patients with a serum creatinine concentration300 micromol/L who were undergoing mechanical ventilation in the intensive care unit and had begun a frusemide infusion as treatment for fluid overload within the previous 24 hours.Patients were randomly allocated to receive either spironolactone (100 mg three times daily) or placebo by nasogastric tube for the duration of the frusemide infusion. Daily serum levels of urea and creatinine, 24-hour urine sodium and potassium levels, fluid balance and 24- hour blood levels of aldosterone, human atrial natriuretic peptide and plasma renin activity were measured throughout the period of frusemide infusion.Change in serum sodium concentration over 48 hours from baseline was 3.0 mmol/L for placebo versus 1.0 mmol/L for the spironolactone group (P = 0.08). Change in serum potassium concentration did not differ between the groups (0.125 mmol/L over 48 hours). There were no significant differences in total urinary sodium or potassium excretion. Serum creatinine, urea, urine volume, fluid balance, potassium requirements and hormone levels were similar in both groups.In this pilot study, the administration of high-dose spironolactone to ventilated critically ill patients receiving frusemide by infusion had no significant effects on serum sodium level, natriuresis or potassium balance when compared with placebo.

Fatal snakebites at Port Moresby General Hospital (PMGH), Papua New Guinea (PNG), were examined to identify interventions that may improve patient survival.Retrospective case series.Inpatients at PMGH who presented with snakebite, had evidence of envenomation, and died as inpatients between 1 January 1992 and 31 December 2001.Number and cause of fatalities; ventilation bed-days; antivenom timing, dose and price.87 deaths occurred among 722 snakebite admissions to the intensive care unit (ICU). Of these 722 patients, 82.5% were ventilated, representing 45% of all ventilated ICU patients and 60% (3430/5717) of all ICU ventilator bed-days. The median duration of ventilation in fatal snakebite cases was significantly less than in non-fatal cases for children (3.0 v. 4.5 days) and adults (3.0 v. 5.0 days). The case-fatality rate for children (14.6%) was significantly greater than that for adults (8.2%). Sixty fatalities were examined in detail: 75% received blood products; 53% received antivenom (mostly a single ampoule of polyvalent), but only 5% received antivenomor = 4 hours post-bite. Major causes of death included respiratory complications (50%), probable intracerebral haemorrhage (17%), and renal failure (10%). Antivenom unit costs increased significantly over the decade; in 2000 an ampoule of polyvalent antivenom was 40-fold more expensive in PNG than in Australia on a gross domestic product (A dollars) per capita basis.Management of severe snakebite is a major challenge for PMGH. Improved antivenom procurement and use policies (including increased use of appropriate monovalent antivenoms), combined with targeted snakebite education interventions (community- and hospital-based), are key interventions to reduce the ongoing toll from snakebite.