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Objective The aim of the study was to determine whether adjunctive hydrocortisone reduced healthcare expenditure and was cost-effective compared with placebo in New Zealand patients in the Adjunctive Glucocorticoid Therapy in Patients with Septic Shock (ADRENAL) trial. Design This is a health economic analysis using data linkage to New Zealand Ministry of Health databases to determine resource use, costs, and cost-effectiveness for a 24-month period. Setting The study was conducted in New Zealand. Participants and intervention Patients with septic shock were randomised to receive a 7-day continuous infusion of 200 mg of hydrocortisone or placebo in the ADRENAL trial. Main outcome measures Healthcare expenditure was associated with all hospital admissions, emergency department presentations, outpatient visits, and pharmacy expenditure. Effectiveness outcomes included mortality at 6 months and 24 months and quality of life at 6 months. Cost-effectiveness outcomes were assessed with reference to quality-adjusted life years gained at 6 months and life years gained at 24 months. Results Of 3800 patients in the ADRENAL trial, 419 (11.0%) were eligible, and 405 (96.7% of those eligible) were included. The mean total costs per patient over 24 months were $143,627 ± 100,890 and $143,772 ± 97,117 for the hydrocortisone and placebo groups, respectively (p = 0.99). Intensive care unit costs for the index admission were $50,492 and $62,288 per patient for the hydrocortisone and placebo groups, respectively (p = 0.09). The mean number of quality-adjusted life years gained at 6 months and mean number of life years gained at 24 months was not significantly different by treatment group, and the probability of hydrocortisone being cost-effective was 55% at 24 months. Conclusions In New Zealand, adjunctive hydrocortisone did not reduce total healthcare expenditure or improve outcomes compared with placebo in patients with septic shock.

Despite evidence showing that optometry-led collaborative glaucoma care can be delivered at reduced cost compared to ophthalmology-based care without compromising patient outcomes, such models of care are not widely practiced in Australia. Ensuring glaucoma patients have equitable access to effective and cost-effective care is a matter of public health importance. This study examined the feasibility and business case assessment for providing glaucoma care from a community optometry perspective. Nine optometrists were interviewed in a semi-structured format, focusing on the economic feasibility, barriers, and benefits of collaborative glaucoma care. The Consolidated Framework for Intervention Research was used for thematic data analysis. Costs and revenues associated with providing glaucoma care were sourced from the literature and interviews. A business case model assessing the profitability of glaucoma care in optometric practice was developed. Thematic analysis revealed concerns over financial viability such that current Medicare Benefits Schedule fees are not sufficient to justify the cost of running a community optometry glaucoma clinic. All participants received a supplementary source of revenue. This finding was confirmed by the business case assessment. Inter-professional trust was perceived to be a key barrier to initiation of collaborative care however was able to be overcome quickly upon commencement of a collaborative care relationship. Optometrists perceived that collaborative care was beneficial to all involved, including patients, ophthalmologists, optometrists, and health payers. There was a perception of a growing divide between clinical and retail optometry, which was thought by most participants to be appropriate. This study is the first to explore the feasibility and business case for community-based optometrists to provide collaborative glaucoma care in Australia. Our findings show that current public funding is insufficient to justify the business case to private optometry practice, despite being perceived by optometrists as beneficial to all involved.

BACKGROUND: The β-Lactam Infusion Group (BLING) III study is a prospective, multicentre, open, phase 3 randomised controlled trial comparing continuous infusion with intermittent infusion of β-lactam antibiotics in 7000 critically ill patients with sepsis. OBJECTIVE: To describe a statistical analysis plan for the BLING III study. METHODS: The statistical analysis plan was designed by the trial statistician and chief investigators and approved by the BLING III management committee before the completion of data collection. Statistical analyses for primary, secondary and tertiary outcomes and planned subgroup analyses are described in detail. Interim analysis by the Data Safety and Monitoring Committee (DSMC) has been conducted in accordance with a pre-specified DSMC charter. RESULTS AND CONCLUSIONS: The statistical analysis plan for the BLING III study is published before completion of data collection and unblinding to minimise analysis bias and facilitate public access and transparent analysis and reporting of study findings. TRIAL REGISTRATION: ClinicalTrials.gov Registry NCT03212990.

Background: It is unclear whether the use of selective decontamination of the digestive tract (SDD) improves outcomes in ventilated patients in intensive care units (ICUs) and whether SDD is associated with the development of antibiotic resistance. Objective: To describe the study protocol and statistical analysis plan for the Selective Decontamination of the Digestive Tract in Intensive Care Unit Patients (SuDDICU) trial. Design, setting, participants and intervention: SuDDICU is an international, crossover, cluster randomised controlled trial of mechanically ventilated patients in ICUs using two 12-month trial periods. For each period, participating ICUs will implement SDD plus standard care or standard care alone. The SuDDICU drug intervention is an oral paste and gastric suspension of three antibiotics combined with a 4-day course of intravenous antibiotics. Observational ecological assessments will be conducted during five surveillance periods. The trial will be conducted in 19 ICUs in Australia and ten ICUs in Canada and the United Kingdom, and will recruit 15 000–17 000 patients. Recruitment commenced in Australia in 2017. Main outcome measures: The primary outcome is all-cause hospital mortality. Secondary outcomes include: duration of ventilation, ICU stay and hospital stay; incidence of new antibiotic-resistant organisms during the index ICU admission; changes in antibiotic-resistant organism rates; incidence of new Clostridioides difficile infections; and total use of antibiotics. Results and conclusions: SuDDICU will determine whether the use of SDD plus standard care is associated with a reduction in hospital mortality in ventilated ICU patients compared with standard care alone. It will also quantify the impact of the use of SDD on the development of antibiotic resistance. Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12615000411549) and ClinicalTrials.gov (NCT02389036).

Background and objective: The Plasma-Lyte 148 versus Saline (PLUS) study is a prospective, multicentre, parallel-group, concealed, blinded, randomised controlled trial comparing the effect of Plasma-Lyte 148 versus 0.9% sodium chloride (saline) for fluid resuscitation and other fluid therapy on 90-day mortality among critically ill adults requiring fluid resuscitation. The original target for recruitment was 8800 participants, which was reduced to 5000 participants following the onset of the coronavirus disease 2019 (COVID-19) pandemic in 2020. This article describes the statistical analysis plan for the PLUS study. Methods: The statistical analysis plan was developed by the study statistician, chief investigator, and project manager, and was approved by the Management Committee before unblinding. The plan describes in detail the analysis of baseline characteristics, process measures, and outcomes, including covariate adjustments, subgroup analyses, missing data handling, and sensitivity analyses. Results and conclusions: A statistical analysis plan for the PLUS study was developed. This pre-specified plan accords with high quality standards of internal validity and should minimise future analysis bias. © 2021, College of Intensive Care Medicine. All rights reserved.

Background Dietary sodium reduction is recommended to reduce the burden of cardiovascular disease. In Vietnam food products including salt, fish sauce and bot canh contribute to ~ 70% of dietary sodium intake. Reduced sodium versions of these products can be produced by replacing some of the sodium chloride with potassium chloride. We aimed to assess the cost-effectiveness of three alternative approaches to introducing reduced sodium products onto the market with a view to lowering population sodium intake in Vietnam. Methods The three salt substitution strategies included voluntary, subsidised and regulatory approaches targeting salt, fish sauce and bot canh products. Costs were modelled using the WHO-CHOICE methodology. A Markov cohort model was developed to evaluate the cost-effectiveness of each strategy versus no intervention from the government perspective. The model linked each intervention strategy to assumed changes in levels of sodium intake and then to systolic blood pressure. Changes in SBP were linked to a probability of ischaemic heart disease or stroke. The model followed people over their lifetime to assess average costs and quality adjusted life years (QALYs) gained for each strategy. Results The voluntary salt substitution strategy was assumed to require no investment by government. Following ramp up (years 6+), the average annual costs for the subsidised and regulatory strategies were 21,808,968,902 ₫ (US$ 977,354) and 12,949,953,247 ₫ (US$ 580,410) respectively. Relative to no intervention, all three salt substitution strategies were found to be cost-effective. Cost savings were driven by reductions in strokes (32,595; 768,384; 2,366,480) and ischaemic heart disease (IHD) events (22,830; 537,157; 1,648,590) for the voluntary, subsidised & regulatory strategies, respectively. The voluntary strategy was least cost-effective (− 3445 ₫ US$ -0.15; 0.009 QALYs gained) followed by the subsidised strategy (− 43,189 ₫ US$ -1.86; 0.022 QALYs gained) and the regulatory strategy delivered the highest cost savings and health gains (− 243,530 ₫ US$ -10.49; 0.074 QALYs gained). Conclusion This research shows that all three modelled salt substitution strategies would be good value for money relative to no intervention in Vietnam. The subsidised alternative would require the highest level of government investment; however the implementation costs will be exceeded by healthcare savings assuming a reasonable time horizon is considered.

Objective Fluid resuscitation is a ubiquitous intervention in the management of patients treated in the intensive care unit, which has implications for intensive care unit resourcing and budgets. Our objective was to calculate the relative cost of resuscitation fluids in several countries to inform future economic evaluations. Methods We collected site-level data regarding the availability and cost of fluids as part of an international survey. We normalised costs to net present values using purchasing power parities and published inflation figures. Costs were also adjusted for equi-effective dosing based on intravascular volume expansion effectiveness and expressed as US dollars (USD) per 100 mL crystalloid equivalent. Results A total of 187 sites had access to cost data. Between countries, there was an approximate six fold variation in the cost of crystalloids and colloids overall. The average cost for crystalloids overall was less than 1 USD per 100 mL. In contrast, colloid fluids had higher average costs (59 USD per 100 mL). After adjusting for equi-effective dosing, saline was ∼27 times less costly than albumin (saline: 0.6 USD per 100 mL crystalloid equivalent; albumin 4–5%: 16.4 USD; albumin 20–25%: 15.8 USD) and ∼4 times less costly than hydroxyethyl starch solution (saline: 0.6 USD; hydroxyethyl starch solution: 2.5 USD). Buffered salt solutions, such as compound sodium acetate solutions (e.g., Plasmalyte®), had the highest average cost of crystalloid fluids, costing between 3 and 4 USD per 100 mL. Conclusion The cost of fluid varies substantially between fluid types and between countries, although normal (0.9%) saline is consistently less costly than colloid preparations and some buffered salt solutions. These data can be used to inform future economic evaluations of fluid preparations.

Whether the use of balanced multielectrolyte solution (BMES) in preference to 0.9% sodium chloride solution (saline) in critically ill patients reduces the risk of acute kidney injury or death is uncertain.In a double-blind, randomized, controlled trial, we assigned critically ill patients to receive BMES (Plasma-Lyte 148) or saline as fluid therapy in the intensive care unit (ICU) for 90 days. The primary outcome was death from any cause within 90 days after randomization. Secondary outcomes were receipt of new renal-replacement therapy and the maximum increase in the creatinine level during ICU stay.A total of 5037 patients were recruited from 53 ICUs in Australia and New Zealand - 2515 patients were assigned to the BMES group and 2522 to the saline group. Death within 90 days after randomization occurred in 530 of 2433 patients (21.8%) in the BMES group and in 530 of 2413 patients (22.0%) in the saline group, for a difference of -0.15 percentage points (95% confidence interval [CI], -3.60 to 3.30; P = 0.90). New renal-replacement therapy was initiated in 306 of 2403 patients (12.7%) in the BMES group and in 310 of 2394 patients (12.9%) in the saline group, for a difference of -0.20 percentage points (95% CI, -2.96 to 2.56). The mean (±SD) maximum increase in serum creatinine level was 0.41±1.06 mg per deciliter (36.6±94.0 μmol per liter) in the BMES group and 0.41±1.02 mg per deciliter (36.1±90.0 μmol per liter) in the saline group, for a difference of 0.01 mg per deciliter (95% CI, -0.05 to 0.06) (0.5 μmol per liter [95% CI, -4.7 to 5.7]). The number of adverse and serious adverse events did not differ meaningfully between the groups.We found no evidence that the risk of death or acute kidney injury among critically ill adults in the ICU was lower with the use of BMES than with saline. (Funded by the National Health and Medical Research Council of Australia and the Health Research Council of New Zealand; PLUS ClinicalTrials.gov number, NCT02721654.).

ImportanceWhether selective decontamination of the digestive tract (SDD) reduces mortality in critically ill patients remains uncertain.ObjectiveTo determine whether SDD reduces in-hospital mortality in critically ill adults.Design, Setting, and ParticipantsA cluster, crossover, randomized clinical trial that recruited 5982 mechanically ventilated adults from 19 intensive care units (ICUs) in Australia between April 2018 and May 2021 (final follow-up, August 2021). A contemporaneous ecological assessment recruited 8599 patients from participating ICUs between May 2017 and August 2021.InterventionsICUs were randomly assigned to adopt or not adopt a SDD strategy for 2 alternating 12-month periods, separated by a 3-month interperiod gap. Patients in the SDD group (n = 2791) received a 6-hourly application of an oral paste and administration of a gastric suspension containing colistin, tobramycin, and nystatin for the duration of mechanical ventilation, plus a 4-day course of an intravenous antibiotic with a suitable antimicrobial spectrum. Patients in the control group (n = 3191) received standard care.Main Outcomes and MeasuresThe primary outcome was in-hospital mortality within 90 days. There were 8 secondary outcomes, including the proportion of patients with new positive blood cultures, antibiotic-resistant organisms (AROs), and Clostridioides difficile infections. For the ecological assessment, a noninferiority margin of 2% was prespecified for 3 outcomes including new cultures of AROs.ResultsOf 5982 patients (mean age, 58.3 years; 36.8% women) enrolled from 19 ICUs, all patients completed the trial. There were 753/2791 (27.0%) and 928/3191 (29.1%) in-hospital deaths in the SDD and standard care groups, respectively (mean difference, −1.7% [95% CI, −4.8% to 1.3%]; odds ratio, 0.91 [95% CI, 0.82-1.02]; P = .12). Of 8 prespecified secondary outcomes, 6 showed no significant differences. In the SDD vs standard care groups, 23.1% vs 34.6% had new ARO cultures (absolute difference, −11.0%; 95% CI, −14.7% to −7.3%), 5.6% vs 8.1% had new positive blood cultures (absolute difference, −1.95%; 95% CI, −3.5% to −0.4%), and 0.5% vs 0.9% had new C difficile infections (absolute difference, −0.24%; 95% CI, −0.6% to 0.1%). In 8599 patients enrolled in the ecological assessment, use of SDD was not shown to be noninferior with regard to the change in the proportion of patients who developed new AROs (−3.3% vs −1.59%; mean difference, −1.71% [1-sided 97.5% CI, −∞ to 4.31%] and 0.88% vs 0.55%; mean difference, −0.32% [1-sided 97.5% CI, −∞ to 5.47%]) in the first and second periods, respectively.Conclusions and RelevanceAmong critically ill patients receiving mechanical ventilation, SDD, compared with standard care without SDD, did not significantly reduce in-hospital mortality. However, the confidence interval around the effect estimate includes a clinically important benefit.Trial RegistrationClinicalTrials.gov Identifier: NCT02389036

Better alignment between health research organisations with the needs (and interests) of key stakeholders in the health policy and research system is critical to improving research impact. The George Institute for Global Health’s ‘Healthier Societies’ program focuses on harnessing the power of governments, markets, and communities to improve population level health equity outcomes and maximise research impact. This protocol outlines a systemic multi-sectoral approach to advance health research impact globally applied to a project to reduce population salt intake in Vietnam by introducing reduced-sodium salts and salty condiments. We defined a systemic multi-sectoral approach to be a strategy that involves engaging with government, market and communities in a deliberate and joined-up way to solve a problem in which they all have a role to play. The project objectives are to: (i) produce reduced-sodium fish sauce products and test consumer acceptability; (ii) investigate the market feasibility of introducing reduced-sodium foods (salt, bot canh and fish sauce) into the Vietnamese market; (iii) estimate the cost-effectiveness of three different government strategies to support the implementation of reduced-sodium products; and (iv) develop an advocacy roadmap to maximise potential research impact. Methods will include standard quality and safety assessments, consumer sensory testing for the locally produced reduced-sodium fish sauces, market feasibility assessment (including collating market data and semi-structured interviews with stakeholders), cost-effectiveness modelling (Markov cohort model), multi-sector stakeholder engagement, and the development of a coordinated advocacy strategy using the Kotter Plus framework. Health research organisations are increasingly seeking ways to achieve greater impact with their research. Through the application of a systemic multi-sectoral approach with governments, markets and communities, this protocol provides an example of how health research projects can achieve such impact.

Cutaneous T-cell lymphoma (CTCL) is a rare and incurable disease, and patients currently experience a lack of treatment options in Australia. This analysis evaluated the cost-effectiveness of extracorporeal photopheresis (ECP) compared with standard of care therapy for the treatment of patients with erythrodermic (stage TA Markov model was developed from the perspective of the Australian government. Health states were treatment specific and transition probabilities were modeled from time-to-next-treatment data from a published Australian observational study of ECP and comparator treatments. Quality of life utility values were based on psoriasis as a proxy for CTCL, which was validated by consultation with local clinicians. The time horizon for the model was 5 years. The ECP treatment regimen was compared with a weighted treatment comparator based on results of a treatment survey and Australian prescribing data.ECP as a second-line treatment option for CTCL was less costly and more effective than other treatment strategies. ECP had an average cost saving of $37 592 and incremental quality-adjusted life-year gained of 0.20 to 0.21, attributed to patients being able to better tolerate ECP thus avoiding subsequent treatment with high-cost alternatives.This is the first published cost-utility analysis of ECP for CTCL. This analysis demonstrates that ECP is a cost-effective option for the treatment of patients with erythrodermic CTCL in Australia.

Purpose Improvement in long-term outcomes through innovative, cost-effective medical technologies is a focus for endovascular procedures aimed at treating symptomatic lower-limb peripheral arterial disease (PAD). The advent of drug-eluting stents (DES) has improved symptomatic PAD treatment via a reduction in high rates of target lesion revascularisation (TLR). The present study aimed to compare the 5-year financial impact of treatment with Eluvia, a new paclitaxel-eluting stent, versus treatment with Zilver PTX, a drug-coated stent, among patients in Australia by developing a budget impact model (BIM). Methods A BIM was developed from an Australian public hospital payer perspective using Australian national cost weights (AUD), published literature, and public hospital audit data. Clinical outcomes, including clinically driven TLRs (CD-TLRs), adverse events, and length of stay, were based on the 2-year results of the IMPERIAL trial, which compared Eluvia DES to Zilver PTX. Results Assuming EVP eligibility rate of 80% and DES uses rate ranging from 10 to 28% (superficial femoral artery lesions only), the 5-year model forecasted a treatment population between 14,428 and 40,399 patients. The model estimated 1499–4198 fewer CD-TLRs and 16,515–46,243 fewer hospital days with Eluvia DES use. This translated to 5-year potential savings of $4.3–$12.1 million to the Australian public hospital payer attributable to reduced CD-TLRs for Eluvia DES and $33.1–$92.6 million to Australian public hospitals owing to reduced adverse events and hospital bed days. Conclusion Eluvia DES use as treatment for symptomatic lower-limb PAD could lead to potential savings for the Australian public healthcare system based on improved patient outcomes.

Objective To conduct a narrative review on the evolution of intensive care and the cost of intensive care services in Australia. Review method A narrative review using a search of online medical databases and grey literature with keyword verification via Delphi-technique. Data sources Using Medical Subject Headings and keywords (intensive care, critical care, mechanical ventilation, renal replacement therapy, extracorporeal membrane oxygenation, monitoring, staffing, cost, cost analysis) we searched MEDLINE, PubMed, CINAHL, Embase, Google and Google Scholar. Results The search yielded 30 articles from which we provide a narrative synthesis on the evolving intensive care practice in relation to key service elements and therapies. For the review of costs, we found five relevant publications and noted significant variation in methods used to cost ICU. Notwithstanding the limitations of the methods used to cost all publications reported staffing as the primary cost driver, representing up to 71% of costs. Conclusion Intensive care is a highly specialised medical field, which has developed rapidly and plays an increasingly important role in the provision of hospital care. Despite the increasing importance of the specialty and the known resource intensity there is a paucity of data on the cost of providing this service. In Australia, staffing costs consistently represent the majority of costs associated with operating an ICU. This finding should be interpreted cautiously given the variation of methods used to cost ICU services and the limited number of available studies. Developing standardised methods to consistently estimate ICU costs which can be incorporated in research into the cost-effectiveness of alternate practice is an important step to ensuring cost-effective care.

β-Lactam antibiotics display a time-dependent mechanism of action, with evidence suggesting improved outcomes when administering these drugs via continuous infusion compared with standard intermittent infusion. However, there is no phase 3 randomised controlled trial (RCT) evidence to support one method of administration over another in critically ill patients with sepsis.The β-Lactam Infusion Group (BLING) III study is a prospective, multicentre, open, phase 3 RCT to compare continuous infusion with standard intermittent infusion of β-lactam antibiotics in critically ill patients with sepsis. The study will be conducted in about 70 intensive care units (ICUs) in Australia, New Zealand, the United Kingdom, Belgium and selected other countries, from 2018 to 2021.BLING III will recruit 7000 critically ill patients with sepsis being treated with one of two β-lactam antibiotics (piperacillin-tazobactam or meropenem) to receive the β-lactam antibiotic by either continuous or intermittent infusion.The primary outcome is allcause mortality within 90 days after randomisation. Secondary outcomes are clinical cure at Day 14 after randomisation, new acquisition, colonisation or infection with a multiresistant organism or Clostridium difficile diarrhoea up to 14 days after randomisation, all-cause ICU mortality and all-cause hospital mortality. Tertiary outcomes are ICU length of stay, hospital length of stay and duration of mechanical ventilation and duration of renal replacement therapy up to 90 days after randomisation.The BLING III study will compare the effect on 90-day mortality of β-lactam antibiotics administered via continuous versus intermittent infusion in 7000 critically ill patients with sepsis.ClinicalTrials.gov Registry (NCT03213990).

IntroductionImproving long-term outcomes like target lesions revascularizations (TLRs) is a focus for endovascular interventions aimed at treating symptomatic lower-limb peripheral arterial disease (PAD). EluviaTM, a paclitaxel-eluting drug-eluting stent (DES) was shown to further reduce TLRs when compared with the paclitaxel-coated Zilver® PTX® stent in the IMPERIAL trial, a global, randomized controlled study. This budget-impact evaluation investigated cost-savings from Eluvia-use when compared with Zilver PTX, relying on the 12- to 24-month outcomes from the IMPERIAL trial.MethodsA budget-impact model comparing Eluvia and Zilver PTX was developed from the Australian public healthcare payer, and an individual hospital perspective, with a 5-year time-horizon. Observed trial results were applied to each year's incident population and associated costs, and no extrapolation was conducted. The analysis used publicly available Australian national hospital cost data, population estimates, procedural statistics, epidemiological literature, and data from public hospital audits to verify eligible population for endovascular procedures (EVP) including DES. All costs were captured in Australian dollars (AUD), where AUD 1 = USD 0.69 (June 2020).ResultsAssuming 80-percent EVP eligibility, and a DES-use range of 10–28 percent, the 5-year model estimated potential national savings of AUD 4.3–12.1 million (M) [USD 3–8.3M] to the public healthcare payer, driven by reduced TLRs from Eluvia-use compared with Zilver-PTX. The model projected potential national savings of AUD 33.1–92.6M (USD 22.8–63.9M) to individual hospitals through reduced hospital bed days for adverse events (AE). The model forecasted 14,428–40,399 treated patients; 1,499–4,198 fewer TLRs; and 16,515–46,243 fewer hospital days for AE. At a state level, projected hospital savings were: New South Wales AUD 10.9–30.7M [USD 7.5–21.1M]; Victoria AUD 8.4–23.4M [USD 5.8–16.1M]; Queensland AUD 6.5–18.3M [USD 4.5–12.6M]; Western Australia AUD 3.4–9.5M [USD 2.3–6.5M]; South Australia AUD 2.3–6.4M [USD 1.6–4.4M].ConclusionsTreatment of symptomatic lower-limb PAD with the Eluvia DES could lead to potential savings for the Australian healthcare system, at the national, state, and the local hospital level, based on improved patient outcomes.

Summary Background Hydroxyethyl starch for fluid resuscitation in critically ill patients is not associated with improved short-term patient-centred outcomes compared with crystalloid fluid solutions. However, its effect on longer term health economic outcomes has not been reported. Methods We did a prespecified cost-effectiveness analysis of a cohort of patients from New South Wales enrolled in the Crystalloid versus Hydroxyethyl Starch Trial (CHEST), who were randomised to treatment with either 6% hydroxyethyl starch with a molecular weight of 130 kD and a molar substitution ratio of 0·4 or 0·9% sodium chloride (saline) for fluid resuscitation. Clinical outcomes were mortality and life-years gained at 6 months and 24 months, health-related quality of life at 6 months, and quality-adjusted life-years gained at 6 months. Health economic outcomes were hospital and intensive-care unit (ICU) resource use and costs at 24 months and cost-effectiveness, which we defined as the probability of reaching a willingness-to-pay threshold of less than A$50 000 per quality-adjusted life-year gained at 6 months and $100 000 per life-year gained at 24 months. CHEST is registered with ClinicalTrials.gov, number NCT00935168. Findings 3537 (51%) of 7000 patients were enrolled into CHEST from New South Wales, of whom 3450 (98%) were included in our cost-effectiveness analysis. Mortality at both 6 months and 24 months did not differ between the hydroxyethyl starch and saline groups (6 months: 397/1684 [24%] vs 382/1706 [22%]; relative risk [RR] 1·05, 95% CI 0·93–1·19; p=0·41; 24 months: 586/1687 [35%] vs 594/1708 [35%]; RR 1·00, 95% CI 0·91–1·10; p=0·89). The mean number of life-years gained at 6 months and 24 months was similar between the hydroxyethyl starch and saline groups (6 months: 0·41 days [SD 0·18] vs 0·41 days [0·17]; p=0·25; 24 months: 1·46 years [SD 0·80] vs 1·47 years [0·79]; p=0·72). At 6 months, the mean health-related quality of life score was 0·67 (SD 0·34) with hydroxyethyl starch versus 0·69 (0·35) with saline (p=0·33). The mean number of quality-adjusted life-years gained did not differ between the hydroxyethyl starch and saline groups at 6 months (0·26 days [SD 0·18] vs 0·26 days [0·18]; p=0·33). Total hospital costs (including ICU costs) at 24 months were similar between the hydroxyethyl starch and saline groups (A$62 196 [55 935] vs $62 617 [56 452]; p=0·83). The probability that hydroxyethyl starch was cost effective was 11% at 6 months and 29% at 24 months. Interpretation Although longer term clinical outcomes did not differ between patients resuscitated with hydroxyethyl starch or saline in the ICU, from a health-care payer's perspective, the probability that hydroxyethyl starch is cost effective in these patients is low. Funding Division of Critical Care and Trauma, George Institute for Global Health.

In Australia the government must balance access to new drugs against the cost to the Pharmaceutical Benefits Scheme. Economic evaluations can be used to ensure health resources are allocated efficiently, maximising patient outcomes for every dollar spent. There are several methods available to assess the efficiency of funding decisions in health care. Examples are cost-effectiveness, cost-utility, cost-minimisation and cost–benefit. The Incremental Cost Effectiveness Ratio is a statistic used to summarise the cost-effectiveness of a new medicine relative to a comparator. It allows the decision maker to compare one treatment to another, thereby quantifying the opportunity cost of decisions.

To determine differences in health-related quality of life (HRQoL), survival and healthcare resource use of critically ill adults with and without sepsis. We conducted a primary propensity score matched analysis of patients with and without sepsis enrolled in a large multicentre clinical trial. Outcomes included HRQoL at 6 months, survival to 2 years, length of ICU and hospital admission and cost of ICU and hospital treatment to 2 years. We obtained linked data for 3442 (97.3%) of 3537 eligible patients and matched 806/905 (89.0%) patients with sepsis with 806/2537 (31.7%) without. After matching, there were no significant differences in the proportion of survivors with and without sepsis reporting problems with mobility (37.8% vs. 38.7%, p = 0.86), self-care (24.7% vs. 26.0%, p = 0.44), usual activities (44.5% vs. 46.8%, p = 0.28), pain/discomfort (42.4% vs. 41.6%, p = 0.54) and anxiety/depression (36.9% vs. 37.7%, p = 0.68). There was no significant difference in survival at 2 years: 482/792 (60.9%) vs. 485/799 (60.7%) (HR 1.01, 95% CI 0.86–1.18, p = 0.94). The initial ICU and hospital admission were longer for patients with sepsis: 10.1 ± 11.9 vs. 8.0 ± 9.8 days (p

Cross-sectional point prevalence studies collect observational data at a single time point and may be used to facilitate subsequent research hypotheses and discovery.We report the process of implementation and substantive outputs of the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS CTG) point prevalence program, conducted in participating intensive care units from 2009 to 2016.Seventy-seven of a maximum 197 adult ICUs across Australia and New Zealand participated in 9 specified study days over 18 days of data collection and collected data on 5043 participants, with an average of 44 ICUs per study day. All eight Australian and New Zealand paediatric ICUs have participated in dedicated simultaneous paediatric study days. Thirteen manuscripts were published in peer-reviewed journals and data have contributed to 14 individual programs of research, including 18 subsequent grant applications for further research.The ANZICS CTG point prevalence program has resulted in the collection of a substantial body of observational data that has facilitated the development and completion of subsequent research programs and provided opportunities for subsequent capacity development.

Background In 2007, the Saline versus Albumin Fluid Evaluation—Translation of Research Into Practice Study (SAFE-TRIPS) reported that 0.9% sodium chloride (saline) and hydroxyethyl starch (HES) were the most commonly used resuscitation fluids in intensive care unit (ICU) patients. Evidence has emerged since 2007 that these fluids are associated with adverse patient-centred outcomes. Based on the published evidence since 2007, we sought to determine the current type of fluid resuscitation used in clinical practice and the predictors of fluid choice and determine whether these have changed between 2007 and 2014. Methods In 2014, an international, cross-sectional study was conducted (Fluid-TRIPS) to document current patterns of intravenous resuscitation fluid use and determine factors associated with fluid choice. We examined univariate and multivariate associations between patients and prescriber characteristics, geographical region and fluid type. Additionally, we report secular trends of resuscitation fluid use in a cohort of ICUs that participated in both the 2007 and 2014 studies. Regression analysis were conducted to determine changes in the administration of crystalloid or colloid between 2007 and 2014. Findings In 2014, a total of 426 ICUs in 27 countries participated. Over the 24 hour study day, 1456/6707 (21.7%) patients received resuscitation fluid during 2716 resuscitation episodes. Crystalloids were administered to 1227/1456 (84.3%) patients during 2208/2716 (81.3%) episodes and colloids to 394/1456 (27.1%) patients during 581/2716 (21.4%) episodes. In multivariate analyses, practice significantly varied between geographical regions. Additionally, patients with a traumatic brain injury were less likely to receive colloid when compared to patients with no trauma (adjusted OR 0.24; 95% CI 0.1 to 0.62; p = 0.003). Patients in the ICU for one or more days where more likely to receive colloid compared to patients in the ICU on their admission date (adjusted OR 1.75; 95% CI 1.27 to 2.41; p =

Background Accurate economic data are fundamental for improving current funding models and ultimately in promoting the efficient delivery of services. The financial burden of a high trauma casemix to designated trauma centres in Australia has not been previously determined, and there is some evidence that the episode funding model used in Australia results in the underfunding of trauma. Aim To describe the costs of acute trauma admissions in trauma centres, identify predictors of higher treatment costs and cost variance in New South Wales (NSW), Australia. Materials and methods Data linkage of admitted trauma patient and financial data provided by 12 Level 1 NSW trauma centres for the 08/09 financial year was performed. Demographic, injury details and injury scores were obtained from trauma registries. Individual patient general ledger costs (actual trauma patient costs), Australian Refined Diagnostic Related Groups (AR-DRG) and state-wide average costs (which form the basis of funding) were obtained. The actual costs incurred by the hospital were then compared with the state-wide AR-DRG average costs. Multivariable multiple linear regression was used for identifying predictors of costs. Results There were 17,522 patients, the average per patient cost was $10,603 and the median was $4628 (interquartile range: $2179–10,148). The actual costs incurred by trauma centres were on average $134 per bed day above AR-DRG costs-determined costs. Falls, road trauma and violence were the highest causes of total cost. Motor cyclists and pedestrians had higher median costs than motor vehicle occupants. As a result of greater numbers, patients with minor injury had comparable total costs with those generated by patients with severe injury. However the median cost of severely injured patients was nearly four times greater. The count of body regions injured, sex, length of stay, serious traumatic brain injury and admission to the Intensive Care Unit were significantly associated with increased costs ( p Conclusion This multicentre trauma costing study demonstrated the feasibility of trauma registry and financial data linkage. Discrepancies between the observed costs of care in these 12 trauma centres and the NSW average AR-DRG costs suggest that trauma care is currently underfunded in NSW.

Objectives To determine if complications from blunt thoracic trauma are reduced with patient-controlled analgesia (PCA) compared with interval analgesic dosing given as needed. Secondary aims were to investigate the influence of PCA on hospital length of stay (LOS) and cost. Methods In this retrospective cohort study, patients were identified using the hospital trauma registry and clinical information department. Data on analgesic method, outcomes and confounders were obtained from the medical record. Costing data were obtained from the case-mix department. The analysis used logistic regression for the primary outcome and a generalised linear model for the secondary outcomes to adjust for potential confounders. Results 227 patients were included. In the PCA group, 17/52 (33%) patients had a complication compared with 26/175 (15%) in the interval dosing group. The adjusted odds for a complication in patients receiving PCA was not significantly different from the adjusted odds in those receiving interval dosing (OR=1.2, 95% CI 0.3 to 4.6, p=0.83). The median LOS was 8.9 days in the PCA group and 4.6 days in the interval dosing group. The adjusted LOS for patients receiving PCA was 10% shorter than those receiving interval dosing (relative difference 0.9, 95% CI 0.6 to 1.3, p=0.52). The median hospital cost was $A11 107 in the PCA group (IQR $A7520–$A15 744) and $A4511 (IQR $A2687–$A8248) in the interval dosing group. The adjusted total hospital costs for patients receiving PCA was 10% higher than for those receiving interval dosing (relative difference 1.1, 95% CI 0.8 to 1.5, p=0.44). Conclusions PCA did not reduce complications, hospital LOS or costs compared with interval analgesic dosing.

Funding rare disease therapies presents a challenge in Australia where there is a legislative requirement to consider cost-effectiveness. Currently the Life Saving Drugs Programme (LSDP) provides subsidised access to high-cost therapies for rare, life-threatening conditions. However the LSDP is currently under review by the Minsiter for Health and future access to rare disease therapies in uncertain. Internationally there is no gold standard model to evaluate and fund rare disease therapies, and considerable variation exists. However, common features of international systems include the opportunity for early stakeholder engagement, flexibility with evidence requirements, cost-effectiveness criteria and transparency in relation to the decision making framework and outcomes. Australians value equality and equal opportunity in relation to health care. To meet these expectations there is a clear need to maintain a separate fit-for-purpose framework to evaluate and fund rare disease therapies drawing on overseas best practice. This will provide certainty for industry to continue to invest in such treatments, as well as ensuring funding recommendations are reflective of Australian values balanced against the need for financial sustainability.

OBJECTIVE: To examine trends in mechanism and outcome of major traumatic injury in adults since the implementation of the New South Wales trauma monitoring program, and to identify factors associated with mortality. DESIGN AND SETTING: Retrospective review of NSW Trauma Registry data from 1 January 2003 to 31 December 2007, including patient demographics, year of injury, and level of trauma centre where definitive treatment was provided. PARTICIPANTS: 9769 people aged ≥ 15 years hospitalised for trauma, with an injury severity score (ISS) > 15. MAIN OUTCOME MEASURES: The NSW Trauma Registry outcome measures included were overall hospital length of stay, length of stay in an intensive care unit and inhospital mortality. RESULTS: There was a decreasing trend in severe trauma presentations in the age group 16-34 years, and an increasing trend in presentations of older people, particularly those aged ≥ 75 years. Road trauma and falls were consistently the commonest injury mechanisms. There were 1328 inhospital deaths (13.6%). Year of injury, level of trauma centre, ISS, head/neck injury and age were all independent predictors of mortality. The odds of mortality was significantly higher among patients receiving definitive care at regional trauma centres compared with Level I centres (odds ratio, 1.34; 95% CI, 1.10-1.63). CONCLUSIONS: Deaths from major trauma in NSW trauma centres have declined since 2003, and definitive care at a Level 1 trauma centre was associated with a survival benefit. More comprehensive trauma data collection with timely analysis will improve injury surveillance and better inform health policy in NSW. Language: en

BACKGROUND: Strategies to prevent pyrexia in patients with acute neurological injury may reduce secondary neuronal damage. The aim of this study was to determine the safety and efficacy of the routine administration of 6 grams/day of intravenous paracetamol in reducing body temperature following severe traumatic brain injury, compared to placebo. METHODS: A multicentre, randomised, blind, placebo-controlled clinical trial in adult patients with traumatic brain injury (TBI). Patients were randomised to receive an intravenous infusion of either 1g of paracetamol or 0.9% sodium chloride (saline) every 4 hours for 72 hours. The primary outcome was the mean difference in core temperature during the study intervention period. RESULTS: Forty-one patients were included in this study: 21 were allocated to paracetamol and 20 to saline. The median (interquartile range) number of doses of study drug was 18 (17-18) in the paracetamol group and 18 (16-18) in the saline group (P = 0.85). From randomisation until 4 hours after the last dose of study treatment, there were 2798 temperature measurements (median 73 [67-76] per patient). The mean ± standard deviation temperature was 37.4±0.5°C in the paracetamol group and 37.7±0.4°C in the saline group (absolute difference -0.3°C; 95% confidence interval -0.6 to 0.0; P = 0.09). There were no significant differences in the use of physical cooling, or episodes of hypotension or hepatic abnormalities, between the two groups. CONCLUSION: The routine administration of 6g/day of intravenous paracetamol did not significantly reduce core body temperature in patients with TBI. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12609000444280. Language: en

Objectives: To compare the proportion of patients exposed to a radiation dose in excess of 20 mSv, and to document missed injuries before and after the introduction of a panscan protocol for blunt trauma. Methods: Data were collected retrospectively from our trauma database for 6 months before and after implementation of the protocol. All radiological studies performed during the initial patient assessment were identified. Radiation doses for each patient were calculated. Subgroup analyses were age 30 and >30 years, injury severity score (ISS) 20 mSv increased by 8% (95% confidence interval [CI] 4‐12), which equated to one extra person being exposed to >20 mSv for every 13 patients treated after the introduction of the protocol. The odds of receiving a radiation dose >20 mSv after the introduction of the protocol compared with the odds before were increased across all subgroups (30 years: odds ratio [OR] 2.7, 95% CI 1.3‐5.8, P = 0.008; >30 years: OR 2.2, 95% CI 1.5‐3.4, P 20 mSv. This increased risk occurred regardless of age or injury severity.

The intravenous fluid 6% hydroxyethyl starch (130/0.4) (6% HES 130/0.4) is used widely for resuscitation but there is limited information on its efficacy and safety. A large-scale multi-centre randomised controlled trial (CHEST) in critically ill patients is currently underway comparing fluid resuscitation with 6% HES 130/0.4 to 0.9% sodium chloride on 90-day mortality and other clinically relevant outcomes including renal injury. This report describes the study protocol.CHEST will recruit 7,000 patients to concealed, random, parallel assignment of either 6% HES 130/0.4 or 0.9% sodium chloride for all fluid resuscitation needs whilst in the intensive care unit (ICU). The primary outcome will be all-cause mortality at 90 days post-randomisation. Secondary outcomes will include incident renal injury, other organ failures, ICU and hospital mortality, length of ICU stay, quality of life at 6 months, health economic analyses and in patients with traumatic brain injury, functional outcome. Subgroup analyses will be conducted in four predefined subgroups. All analyses will be conducted on an intention-to-treat basis.The study run-in phase has been completed and the main trial commenced in April 2010. CHEST should generate results that will inform and influence prescribing of this commonly used resuscitation fluid.

Elevation of body temperature is common after traumatic brain injury (TBI). Suppressing fever may be beneficial.In clinical practice, temperature is maintained _37°C.A retrospective, multicentre, cohort study of patients with an intensive care unit admission diagnosis of TBI over a 6-month period.The mean proportion of time per day that temperature _37°C or _38°C (to correct for unequal measurements between patients, imputation was used between consecutive temperature measurements and a linear relationship was assumed); and the proportion of patients on each day with a peak temperature _37°C.217 patients with TBI were admitted to eight ICUs. The mean Acute Physiology and Chronic Health Evaluation II score of the cohort was 15.7 (SD, 7.7) and intracranial pressure monitoring was done in 29% of patients. The mean proportion of time on each day that temperature was _37°C varied between 56% (SE, 2.6%) on Day 1 and 89% (SE, 3.7%) on Day 14. The mean proportion of time per day that temperature was38°C was between a minimum of 11% (SE, 1.5%) on Day 1 and a maximum of 25% (SE, 4.4%) Day 11. The proportion of patients for whom daily peak temperature was37°C ranged between a minimum of 73.2% (153/209) on Day 1 and a maximum of 97.4% (26/33) on Day 13.In patients with TBI, a substantial proportion of time is spent with a temperature _37°C. Prospective validation of these data are required.

Injuries are a major source of mortality and morbidity in China with approximately 66 million citizens requiring emergency medical care. Trauma registries provide the basis for quality assurance processes and inform the treatment of the injured patient. Against the backdrop of the recently established Chinese National Injury Surveillance System, the feasibility of establishing a multicentre trauma registry in a limited number of hospitals was examined. Seven hospital directors reported on a range of hospital characteristics including patient volume information and the types of patient information routinely collected. The findings indicate significant numbers of patients presenting due to injury, though little comparability in the type of information collected both between hospitals and with international trauma registry systems. The development of multicentre trauma registry is suggested as a way to monitor trauma system performance. The integration of clinical indicators into the National Injury Surveillance System in the long term is also recommended.

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.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.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.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.

Background Despite numerous studies evaluating the benefits of Helicopter Emergency Medical Services (HEMS) in primary scene responses, little information exists on the scope of HEMS activities in Australia. We describe HEMS primary scene responses with respect to the time taken, the distances travelled relative to the closest designated trauma hospital and the receiving hospital; as well as the clinical characteristics of patients attended. Methods Clinical service data were retrospectively obtained from three HEMS in New South Wales between July 2008 and June 2009. All available primary scene response data were extracted and examined. Geographic Information System (GIS) based network analysis was used to estimate hypothetical ground transport distances from the locality of each primary scene response to firstly the closest designated trauma hospital and secondly the receiving hospital. Predictors of bypassing the closest designated trauma hospital were analysed using logistic regression. Results Analyses included 596 primary missions. Overall the HEMS had a median return trip time of 94min including a median of 9min for activation, 34min travelling to the scene, 30min on-scene and 25min transporting patients to the receiving hospital. 72% of missions were within 100km of the receiving hospital and 87% of missions were in areas classified as ‘major cities’ or ‘inner regional’. The majority of incidents attended by HEMS were trauma-related, with road trauma the predominant cause (44%). The majority of trauma patients (81%) had normal physiology at HEMS arrival (RTS = 7.84). We found 62% of missions bypassed the closest designated trauma hospital. Multivariate predictors of bypass included: age; presence of spinal or burns trauma; the level of the closest designated trauma hospital; the transporting HEMS. Conclusion Our results document the large distances travelled by HEMS in NSW, especially in rural areas. The high proportion of HEMS missions that bypass the closest designated trauma hospital is a seldom mentioned benefit of HEMS transport. These results along with the characteristics of patients attended and the time HEMS take to complete primary scene responses are useful in understanding the benefit HEMS provides and the services it replaces.

Background In NSW Australia, a formal trauma system including the use of helicopter emergency medical services (HEMS) has existed for over 20 years. Despite providing many advantages in NSW, HEMS patients are frequently over-triaged; leading to financial implications for major trauma centres that receive HEMS patients. The aim of this study was to investigate the financial implications of HEMS over-triage from the perspective of major trauma centres in NSW. Methods The study sample included all trauma patients transported via HEMS to 12 major trauma centres in NSW during the period: 1 July 2008 to 30 June 2009. Clinical data were gathered from individual hospital trauma registries and merged with financial information obtained from casemix units at respective hospitals. HEMS over-triage was estimated based on the local definition of minor to moderate trauma (ISS≤12) and hospital length of stay of less than 24 hrs. The actual treatment costs were determined and compared to state-wide peer group averages to obtain estimates of potential funding discrepancies. Results A total of 707 patients transported by HEMS were identified, including 72% pre-hospital (PH; n=507) and 28% inter-hospital (IH; n=200) transports. Over-triage was estimated at 51% for PH patients and 29% for IH patients. Compared to PH patients, IH patients were more costly to treat on average (IH: $42,604; PH: $25,162), however PH patients were more costly overall ($12,329,618 [PH]; $8,265,152 [IH]). When comparing actual treatment costs to peer group averages we found potential funding discrepancies ranging between 4% and 32% across patient groups. Using a sensitivity analysis, the potential funding discrepancy increased with increasing levels of over-triage. Conclusions HEMS patients are frequently over-triaged in NSW, leading to funding implications for major trauma centres. In general, HEMS patient treatment costs are higher than the peer group average and the potential funding discrepancy varies by injury severity and the type of transport performed. Although severely injured HEMS patients are more costly to treat, HEMS patients with minor injuries make up the majority of HEMS transports and have larger relative potential funding discrepancies. Future episode funding models need to account for the variability of trauma patients and the proportion of patients transported via HEMS.

Background and context Helicopter Emergency Medical Services (HEMS) are highly resource-intensive facilities that are well established as part of trauma systems in many high-income countries. We evaluated the cost-effectiveness of a physician-staffed HEMS intervention in combination with treatment at a major trauma centre versus ground ambulance or indirect transport (via a referral hospital) in New South Wales (NSW), Australia. Methods Cost and effectiveness estimates were derived from a cohort of trauma patients arriving at St George Hospital in NSW, Australia during an 11-year period. Adjusted estimates of in-hospital mortality were derived using logistic regression and adjusted hospital costs were estimated through a general linear model incorporating a gamma distribution and log link. These estimates along with other assumptions were incorporated into a Markov model with an annual cycle length to estimate a cost per life saved and a cost per life-year saved at one year and over a patient's lifetime respectively in three patient groups (all patients; patients with serious injury [Injury Severity Score > 12]; patients with traumatic brain injury [TBI]). Results Results showed HEMS to be more costly but more effective at reducing in-hospital mortality leading to a cost per life saved of $1,566,379, $533,781 and $519,787 in all patients, patients with serious injury and patients with TBI respectively. When modelled over a patient's lifetime, the improved mortality associated with HEMS led to a cost per life year saved of $96,524, $50,035 and $49,159 in the three patient groups respectively. Sensitivity analyses revealed a higher probability of HEMS being cost-effective in patients with serious injury and TBI. Conclusion Our investigation confirms a HEMS intervention is associated with improved mortality in trauma patients, especially in patients with serious injury and TBI. The improved benefit of HEMS in patients with serious injury and TBI leads to improved estimated cost-effectiveness.

To determine the attitudes of critical care clinicians in Australia and New Zealand towards fever management for critically ill patients with sepsis but without neurological injury.Online scenario-based survey distributed to members of the Australian and New Zealand Intensive Care Society Clinical Trials Group and their intensive care colleagues.The choice of intervention and preferred threshold temperature for modification of temperature in clinical practice and in a clinical trial.Most respondents indicated a preference for the use of interventions to lower temperature at or below 39.0°C (80%; 337/423), with first-line preference being a combination of paracetamol and physical cooling. Secondline interventions included the addition of intensive physical cooling. Doctors chose higher temperature thresholds for intervention (32% [43/134] below 38.5°C and 27% [36/134] above 39.5°C) than nurses (78% [226/289] and 7% [19/289], respectively), who, in turn, indicated stronger preferences for the use of physical cooling. There is support (78%) for a clinical trial of fever management, with respondents suggesting randomising patients to a mean intensive control of temperature to 38.0°C versus a permissive approach with a threshold for intervention of between 38.8°×C (SD, 0.6°C) (nurses) and 39.5°C (SD, 0.7°C) (doctors).There is considerable variability in attitudes to fever management with a reported tendency to act to reduce fever in febrile patients with sepsis. There was broad support for a clinical trial of fever management.

There are indications that compliance with routine clinical practices in intensive care units (ICU) varies widely internationally, but it is currently unknown whether this is the case throughout Australia and New Zealand. A one-day point prevalence study measured the prevalence of routine care processes being delivered in Australian and New Zealand ICUs including the assessment and/or management of: nutrition, pain, sedation, weaning from mechanical ventilation, head of bed elevation, deep venous thrombosis prophylaxis, stress ulcer prophylaxis, blood glucose, pressure areas and bowel action. Using a sample of 50 adult ICUs, prevalence data were collected for 662 patients with a median age of 65 years and a median Acute Physiology and Chronic Health Evaluation II score of 18. Wide variations in compliance were evident in several care components including: assessment of nutritional goals (74%, interquartile range [IQR] 51 to 89%), pain score (35%, IQR 17 to 62%), sedation score (89%, IQR 50 to 100%); care of ventilated patients e.g. head of bed elevation >30 degrees (33%, IQR 7 to 62%) and setting weaning plans (50%, IQR 28 to 78%); pressure area risk assessment (78%, IQR 18 to 100%) and constipation management plan (43%, IQR 6 to 87%). Care components that were delivered more consistently included nutrition delivery (100%, IQR 100 to 100%), deep venous thrombosis (96%, IQR 89 to 100%) and stress ulcer (90%, IQR 78 to 100%) prophylaxis, and checking blood sugar levels (93%, IQR 88 to 100%). This point prevalence study demonstrated variability in the delivery of ‘routine’ cares in Australian and New Zealand ICUs. This may be driven in part by lack of consensus on what is best practice in intensive care units, prompting the need for further research in this area.

Background Injuries represent a significant and growing public health concern in China. This Review was conducted to document the characteristics of injured patients presenting to the emergency department of Chinese hospitals and to assess of the nature of information collected and reported in published surveillance studies. Methods A systematic search of MEDLINE and China Academic Journals supplemented with a hand search of journals was performed. Studies published in the period 1997 to 2007 were included and research published in Chinese was the focus. Search terms included emergency, injury, medical care. Results Of the 268 studies identified, 13 were injury surveillance studies set in the emergency department. Nine were collaborative studies of which eight were prospective studies. Of the five single centre studies only one was of a prospective design. Transport, falls and industrial injuries were common mechanisms of injury. Study strengths were large patient sample sizes and for the collaborative studies a large number of participating hospitals. There was however limited use of internationally recognised injury classification and severity coding indices. Conclusion Despite the limited number of studies identified, the scope of each highlights the willingness and the capacity to conduct surveillance studies in the emergency department. This Review highlights the need for the adoption of standardized injury coding indices in the collection and reporting of patient health data. While high level injury surveillance systems focus on population-based priority setting, this Review demonstrates the need to establish an internationally comparable trauma registry that would permit monitoring of the trauma system and would by extension facilitate the optimal care of the injured patient through the development of informed quality assurance programs and the implementation of evidence-based health policy.

Objective: To determine the attitudes of critical care clinicians in Australia and New Zealand towards fever management for critically ill patients with sepsis but without neurological injury. Design: Online scenario-based survey distributed to members of the Australian and New Zealand Intensive Care Society Clinical Trials Group and their intensive care colleagues. Main outcome measures: The choice of intervention and preferred threshold temperature for modification of temperature in clinical practice and in a clinical trial. Results: Most respondents indicated a preference for the use of interventions to lower temperature at or below 39.0degreesC (80%; 337/423), with first-line preference being a combination of paracetamol and physical cooling. Secondline interventions included the addition of intensive physical cooling. Doctors chose higher temperature thresholds for intervention (32% [43/134] below 38.5degreesC and 27% [36/134] above 39.5degreesC) than nurses (78% [226/289] and 7% [19/289], respectively), who, in turn, indicated stronger preferences for the use of physical cooling. There is support (78%) for a clinical trial of fever management, with respondents suggesting randomising patients to a mean intensive control of temperature to 38.0degreesC versus a permissive approach with a threshold for intervention of between 38.8degrees C (SD, 0.6degreesC) (nurses) and 39.5degreesC (SD, 0.7degreesC) (doctors). Conclusion: There is considerable variability in attitudes to fever management with a reported tendency to act to reduce fever in febrile patients with sepsis. There was broad support for a clinical trial of fever management.