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Objective: To report longitudinal differences in baseline characteristics, treatment, and outcomes in patients with coronavirus disease 2019 (COVID-19) admitted to intensive care units (ICUs) between the first and second waves of COVID-19 in Australia. Design, setting and participants: SPRINT-SARI Australia is a multicentre, inception cohort study enrolling adult patients with COVID-19 admitted to participating ICUs. The first wave of COVID-19 was from 27 February to 30 June 2020, and the second wave was from 1 July to 22 October 2020. Results: A total of 461 patients were recruited in 53 ICUs across Australia; a higher number were admitted to the ICU during the second wave compared with the first: 255 (55.3%) versus 206 (44.7%). Patients admitted to the ICU in the second wave were younger (58.0 v 64.0 years; P = 0.001) and less commonly male (68.9% v 60.0%; P = 0.045), although Acute Physiology and Chronic Health Evaluation (APACHE) II scores were similar (14 v 14; P = 0.998). High flow oxygen use (75.2% v 43.4%; P < 0.001) and non-invasive ventilation (16.5% v 7.1%; P = 0.002) were more common in the second wave, as was steroid use (95.0% v 30.3%; P < 0.001). ICU length of stay was shorter (6.0 v 8.4 days; P = 0.003). In-hospital mortality was similar (12.2% v 14.6%; P = 0.452), but observed mortality decreased over time and patients were more likely to be discharged alive earlier in their ICU admission (hazard ratio, 1.43; 95% CI, 1.13-1.79; P = 0.002). Conclusion: During the second wave of COVID-19 in Australia, ICU length of stay and observed mortality decreased over time. Multiple factors were associated with this, including changes in clinical management, the adoption of new evidence-based treatments, and changes in patient demographic characteristics but not illness severity., Competing Interests: No relevant disclosures., (© 2021 College of Intensive Care Medicine of Australia and New Zealand.)

The global 2019 coronavirus disease (COVID-19) pandemic has led to major challenges in clinical decision making when the demand for intensive care exceeds local capacity. In order to promote consistent, transparent, objective and ethical decision making, the Australian and New Zealand Intensive Care Society (ANZICS) formed a committee to urgently develop guidelines outlining key principles that should be utilised during the pandemic. This guidance is intended to support the practice of intensive care specialists during the COVID-19 pandemic and to promote the development of local admission policies that should be endorsed by health care organisations and relevant local authorities.

Background and Objective: An influenza pandemic has the potential to overwhelm intensive care resources, but the views of the general public on how resources should be allocated in such a scenario were unknown. We aimed to determine Australian and New Zealand public opinion on how intensive care unit beds should be allocated during an influenza pandemic., Design, Setting, and Participants: A postal questionnaire was sent to 4000 randomly selected registered voters; 2000 people each from the Australian Electoral Commission and New Zealand Electoral Commission rolls., Main Outcome Measure: The respondents' preferred method to triage ICU patients in an influenza pandemic. Respondents chose from six methods: use a "first in, first served" approach; allow a senior doctor to decide; use pre-determined health department criteria; use random selection; use the patient's ability to pay; use the importance of the patient to decide. Respondents also rated each of the triage methods for fairness., Results: Australian respondents preferred that patients be triaged to the ICU either by a senior doctor (43.2%) or by pre-determined health department criteria (38.7%). New Zealand respondents preferred that triage be performed by a senior doctor (45.9%). Respondents from both countries perceived triage by a senior doctor and by pre-determined health department criteria to be fair, and the other four methods of triage to be unfair., Conclusion: In an influenza pandemic, when ICU resources would be overwhelmed, survey respondents preferred that ICU triage be performed by a senior doctor, but also perceived the use of pre-determined triage criteria to be fair.

Objective: To determine whether survival following out-of- hospital cardiac arrest (OHCA) in Sydney, Australia, improved between 2004-2005 and 2009-2010, and whether there was a change in incidence of OHCA., Design: Retrospective study using the Ambulance Service of New South Wales and NSW Registry of Births, Deaths and Marriages databases., Participants and Setting: All patients who had an OHCA in the Sydney metropolitan area and who used the Ambulance Service of NSW between June 2009 and May 2010 (2009-2010), and between June 2004 and May 2005 (2004-2005)., Main Outcome Measures: Survival to 90 days. Other outcome measures included the incidence of OHCA and survival to the day following OHCA, 28 days and 1 year following OHCA. Survival and incidence were also calculated according to initial electrocardiograph rhythm., Results: Survival to 90 days was 12.3% in 2004-2005 and 10.2% in 2009-2010 (P = 0.015). In 2004-2005, the age standardised incidence of OHCA was 52.6 events per 100 000 person-years (95% CI, 51.6-53.6 events per 100 000 person-years), and in 2009-2010 it was 48.4 events per 100 000 person-years (95% CI, 46.3-50.4 events per 100 000 person-years). In 2004-2005, the incidence of ventricular fibrillation (VF) was 31.3% (95% CI, 28.4%- 33.9%) and in 2009-2010 it was 22.1% (95% CI, 20.0%- 24.3%)., Conclusion: There was no improvement in survival following OHCA in Sydney between 2004-2005 and 2009- 2010. There has been a decrease in overall survival from OHCA and a decrease in the overall age-standardised incidence of OHCA. The decrease in overall survival may be due to a decline in the incidence of VF.

Objectives: To develop an influenza pandemic ICU triage (iPIT) protocol that excludes patients with the highest and lowest predicted mortality rates, and to determine the increase in ICU bed availability that would result., Design and Setting: Post-hoc analysis of a study evaluating two triage protocols, designed to determine which patients should be excluded from access to ICU resources during an influenza pandemic. ICU mortality rates were determined for the individual triage criteria in the protocols and included criteria based on the Sequential Organ Failure Assessment (SOFA) score. Criteria resulting in mortality rates outside the 25th and 75th percentiles were used as exclusion criteria in a new iPIT-1 protocol. The SOFA threshold component was modified further and reported as iPIT-2 and iPIT-3., Main Outcome Measure: Increase in ICU bed availability., Results: The 25th and 75th percentiles for ICU mortality were 8.3% and 35.2%, respectively. Applying the iPIT-1 protocol resulted in an increase in ICU bed availability at admission of 71.7% ± 0.6%. Decreasing the lower SOFA score exclusion criteria to ≤6 (iPIT-2) and ≤4 (iPIT-3) resulted in an increase in ICU bed availability at admission of 66.9% ± 0.6% and 59.4 ± 0.7%, respectively (P < 0.001)., Conclusion: The iPIT protocol excludes patients with the lowest and highest ICU mortality, and provides increases in ICU bed availability. Adjusting the lower SOFA score exclusion limit provides a method of escalation or de- escalation to cope with demand.

Objectives: To determine whether palliative care teams can improve patient, family and staff satisfaction for patients receiving end-of-life care in the intensive care unit and reduce surrogate markers of health care costs., Design: Randomised controlled, feasibility study., Setting: 14-bed general ICU over 29 months in 2006-2008., Participants: Patients admitted with a terminal or preterminal condition, for whom the treating intensivist considered that escalating or continuing treatment was unlikely to achieve significant improvement in the patient's clinical condition., Intervention: A consultation from a palliative care team, in addition to usual ICU end-of-life care., Main Outcome Measures: ICU and hospital length of stay, and changes in composite scores of satisfaction obtained from questionnaires administered to families, nursing staff and intensivists., Results: The study was constrained by significant logistical and methodological problems, including low recruitment and questionnaire completion rates, and the lack of an available validated questionnaire. From a total of 2009 admissions over a 29-month period, 20 patients were enrolled, 10 in each group. There were significant differences in baseline characteristics. There were no statistically significant differences between those who had a consultation with the palliative care team and those who did not in median ICU length of stay (3 days v 5 days, P=0.97), median hospital length of stay (5 days v 11 days, P=0.44), or changes in overall composite satisfaction scores reported by families (-6% v -6%, P=0.91), nursing staff (+5% v +15%, P=0.30), and intensivists (-2% v +2%, P=0.42)., Conclusion: This feasibility study was difficult to conduct and did not generate any robust conclusions about the utility of involving palliative care teams in end-of-life care in the ICU. Larger studies are technically possible but unlikely to be feasible., Trial Registration: Australian Clinical Trials Registry ACTRN012606000110583.

Objective: To determine whether operators with less than 3 months' formal anaesthesiology training have higher rates of complications when performing endotracheal intubation (ETI) in the intensive care unit than operators with longer formal anaesthesiology training., Design and Setting: Prospective, single-centre, observational study of consecutive ETIs performed in a general, urban, tertiary ICU between May 2005 and May 2008. Data were collected by self-reported, written questionnaire., Participants: The two pre-defined study cohorts were ETIs performed where the initial operator had less than 3 months' formal training in anaesthesiology, and those where the initial operator had 3 months' or longer training., Main Outcome Measures: The primary outcome measure was the number of ETIs where one or more pre-defined complications occurred as a result of the ETI. Secondary outcome measures were the number of ETIs where one or more respiratory, cardiovascular or trauma complications occurred as a result of the ETI, and the number where the airway was deemed difficult by the operator., Results: Data were collected on 276 ETIs. There were no significant differences in primary or secondary outcome measures between the two main study groups. Operators with less than 3 months' formal training in anaesthesiology had a higher level of medical supervision or assistance (75% v 29%, P<0.001), more favourable patient pre-intubation oxygen saturation on pulse oximetry (SpO(2)) (76% v 65% had SpO(2)>89%, P=0.05), and easier resultant grade of intubation (70% v 56% of intubations were Grade I, P= 0.04), but required more operators (19% v 3% required two operators, P<0.001), and more attempts before ETI was successful (62% v 82% of intubations were successful on first attempt, P<0.001)., Conclusion: ETIs performed in the ICU where the initial operator has less than 3 months' formal training in anaesthesiology appear not to be associated with more complications. However, this may be attributable to less experienced operators having more assistance and supervision, and to patient selection.

Objective: To determine whether the introduction of a weekly multidisciplinary team meeting (MDTM) to a general intensive care unit improved selected clinical indicators of patient outcome, and staff satisfaction with patient care., Design: A single-centre, observational, before-and-after study., Setting: A 14-bed general ICU in an urban, tertiary teaching hospital., Study Population: All patients admitted to the ICU during June-December 2006 (before the intervention) and June- December 2007 (after the intervention), and staff employed in the ICU in December 2006 and December 2007., Intervention: Introduction of a weekly MDTM to the ICU., Main Outcome Measures: The primary outcome was the number of patients who stayed in the ICU longer than 5 days. Secondary outcomes included nurses' scores for satisfaction with patient care on a questionnaire; ICU and hospital mortality; duration of mechanical ventilation; readmissions to the ICU within 72 hours of discharge; and after-hours discharges., Results: There were 376 ICU admissions in the "before" period and 432 in the "after" period. Baseline characteristics of the two groups were similar except for a lower proportion of patients admitted directly to the ICU from the operating theatres in the after period (34.2% v 45.2%, P = 0.002). There were no significant differences in any of the primary or secondary outcomes, with the exception of one questionnaire score: a fall in the score nursing staff gave for value of all meetings held in the ICU following the introduction of the MDTM (from 6.6 to 3.9 on a scale of 0-10, P = 0.001)., Conclusion: The introduction of a weekly MDTM to a general ICU did not improve selected clinical indicators of patient outcome or staff satisfaction with patient care.

Recommendations exist to guide the design and construction of adult intensive care units, but current guidelines are hampered by the paucity of high-quality research. Much of the current literature on ICU design has focused on patient-centred outcomes, such as nosocomial infections, aspects of psychological and physiological wellbeing, and patient satisfaction, but the design of the ICU environment also affects health care workers. The literature seems to favour the use of single rooms rather than an open-plan ICU design, with the major benefits being to infection control, but this notion is controversial. For most aspects of ICU design, more research is required before definite conclusions can be drawn. This article discusses the application of evidence-based design to improve the ICU environment and reviews some of the controversial issues and concepts.

Background: Out-of-hospital cardiac arrest (OHCA) is a significant cause of death, but there is little published information on its incidence and outcomes in Australia., Aim: This study was undertaken to determine the incidence and survival from OHCA in Sydney, New South Wales., Methods: Patients listed on the Ambulance Service of NSW database as having an OHCA during the 12-month period 1 June 2004 to 31 May 2005 were matched with the NSW Registry of Births, Deaths and Marriages to determine if they had died, and how long they survived. Survival was also determined for patients aged 80 years or older, and for the presenting electrocardiograph (ECG) rhythm., Results: OHCAs were recorded for 2011 people in a population of 3.993 million. The age-standardised incidence was 52.6 events per 100,000 person-years (95% CI, 51.6-53.6). Incidence was significantly higher in older age groups. Only 24% of patients survived past the day of the OHCA. Survival for 28 days, 90 days and 1 year was 12.6%, 12.2%, and 11.5%, respectively. Survival was highest when the presentation ECG was ventricular fibrillation. Patients aged 80 years or older had lower survival rates., Conclusion: Survival from OHCA in Sydney is low, and lower in patients aged 80 years or older. The incidence of OHCA in Sydney is similar to that in the rest of the world. Mortality occurs early after OHCA. Hence, for interventions to be effective in improving survival, they need to be targeted at the early stages of OHCA.