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Background: Central venous access device (CVAD) is a common procedure in ICU which, although generally safe, can lead to acute and delayed complications. Training and accreditation process for its insertion vary worldwide. Aims: The objective of this study was to explore variability in existing training and accreditation processes for central venous access device (CVAD) insertion among different intensive care units (ICU), current practices of CVAD insertion among fellows of the College of Intensive Care Medicine (CICM) working in Australia and New Zealand (ANZ) and their recommendations for improvement. Methods: A prospective cross‐sectional web‐based survey was sent through email and CICM e‐newsletter to intensivists and directors of ICU across ANZ. All responses were tabulated, post‐hoc exploratory analysis using multivariable ordinal logistic regression was used and free texts were analysed thematically and summarised. Results: A total of 115 responses was received from various public and private ICU from all states of ANZ; 32% of the participants did not have any accreditation process for CVAD insertion skill in their ICU, whereas 91% of respondents revealed there were no processes to assess deskilling. Most intensivists recommended supervision, simulation, various education tools and ultrasound training to improve training and assessment. Thirty‐five percent of the participants inserted 0–5 CVAD and more than half of the intensivists had inserted <10 CVAD in a 1‐year period. Two‐thirds of the respondents recommended inserting between 6 and 20 CVAD each year to maintain competence. Conclusion: The study identified wide variability in current practice, training methods and accreditation process for CVAD insertion among intensivists and ICU trainees in ANZ. Policy makers should consider revising the current clinical practice and training policies to new policies for accreditation and ongoing assessment for CVAD insertions across ANZ ICU. [ABSTRACT FROM AUTHOR]

Background: Virtual communication has become common practice during the coronavirus disease 2019 (COVID‐19) pandemic because of visitation restrictions. Aims: The authors aimed to evaluate overall family satisfaction with the intensive care unit (FS‐ICU) care involving virtual communication strategies during the COVID‐19 pandemic period. Methods: In this prospective multicentre study involving three metropolitan hospitals in Melbourne, Australia, the next of kin (NOK) of all eligible ICU patients between 1 July 2020 and 31 October 2020 were requested to complete an adapted version of the FS‐ICU 24‐questionnaire. Group comparisons were analysed and calculated for family satisfaction scores: ICU/care (satisfaction with care), FS‐ICU/dm (satisfaction with information/decision‐making) and FS‐ICU/total (overall satisfaction with the ICU). The essential predictors that influence family satisfaction were identified using quantitative and qualitative analyses. Results: Seventy‐three of the 227 patients' NOK who initially agreed completed the FS‐ICU questionnaire (response rate 32.2%). The mean FS‐ICU/total was 63.9 (standard deviation [SD], 30.8). The mean score for satisfaction with FS‐ICU/dm was lower than the FS‐ICU/care (62.1 [SD, 30.3) vs 65.4 (SD, 31.4); P < 0.001]. There was no difference in mean FS‐ICU/total scores between survivors (n = 65; 89%) and non‐survivors (n = 8, 11%). Higher patient Acute Physiology and Chronic Health Evaluation III score, female NOK and the patient dying in the ICU were independent predictors for FS‐ICU/total score, while a telephone call at least once a day by an ICU doctor was related to family satisfaction for FS‐ICU/dm. Conclusions: There was low overall family satisfaction with ICU care and virtual communication strategies adopted during the COVID‐19 pandemic. Efforts should be targeted for improving factors with virtual communication that cause low family satisfaction during the COVID‐19 pandemic. [ABSTRACT FROM AUTHOR]

Background: The presence of treatment limitations in patients with frailty at intensive care unit (ICU) admission is unknown. We aimed to evaluate the presence and predictors of treatment limitations in patients with and without COVID‐19 pneumonitis in those admitted to Australian and New Zealand ICUs. Methods: This registry‐based multicenter, retrospective cohort study included all frail adults (≥16 years) with documented clinical frailty scale (CFS) scores, admitted to ICUs with admission diagnostic codes for viral pneumonia or acute respiratory distress syndrome (ARDS) over 2 years between January 01, 2020 and December 31, 2021. Frail patients (CFS ≥5) coded as having viral pneumonitis or ARDS due to COVID‐19 were compared to those with other causes of viral pneumonitis or ARDS for documented treatment limitations. Results: 884 frail patients were included in the final analysis from 129 public and private ICUs. 369 patients (41.7%) had confirmed COVID‐19. There were more male patients in COVID‐19 (55.3% vs 47.0%; p = 0.015). There were no differences in age or APACHE‐III scores between the two groups. Overall, 36.0% (318/884) had treatment limitations, but similar between the two groups (35.8% [132/369] vs 36.1% [186/515]; p = 0.92). After adjusting for confounders, increasing frailty (OR = 1.72; 95%‐CI 1.39–2.14), age (OR = 1.05; 95%‐CI 1.04–1.06), and presence of chronic respiratory condition (OR = 1.58; 95%‐CI 1.10–2.27) increased the likelihood of instituting treatment limitations. However, the presence of COVID‐19 by itself did not influence treatment limitations (odds ratio [OR] = 1.39; 95%‐CI 0.98–1.96). Conclusions: The proportion of treatment limitations was similar in patients with frailty with or without COVID‐19 pneumonitis at ICU admission. [ABSTRACT FROM AUTHOR]

Background: Tracheostomy is a commonly performed procedure in patients with coronavirus disease 2019 (COVID‐19) receiving mechanical ventilation (MV). This review aims to investigate the occurrence of SARS‐CoV‐2 transmission from patients to healthcare workers (HCWs) when tracheostomies are performed. Methods: This systematic review used the preferred reporting items for systematic reviews and meta‐analysis framework. Studies reporting SARS‐CoV‐2 infection in HCWs involved in tracheostomy procedures were included. Results: Sixty‐nine studies (between 01/11/2019 and 16/01/2022) reporting 3117 tracheostomy events were included, 45.9% (1430/3117) were performed surgically. The mean time from MV initiation to tracheostomy was 16.7 ± 7.9 days. Location of tracheostomy, personal protective equipment used, and anaesthesia technique varied between studies. The mean procedure duration was 14.1 ± 7.5 minutes; was statistically longer for percutaneous tracheostomies compared with surgical tracheostomies (mean duration 17.5 ± 7.0 versus 15.5 ± 5.6 minutes, p = 0.02). Across 5 out of 69 studies that reported 311 tracheostomies, 34 HCWs tested positive for SARS‐CoV‐2 and 23/34 (67.6%) were associated with percutaneous tracheostomies. Conclusions: In this systematic review we found that SARS‐CoV‐2 transmission to HCWs performing or assisting with a tracheostomy procedure appeared to be low, with all reported transmissions occurring in 2020, prior to vaccinations and more recent strains of SARS‐CoV‐2. Transmissions may be higher with percutaneous tracheostomies. However, an accurate estimation of infection risk was not possible in the absence of the actual number of HCWs exposed to the risk during the procedure and the inability to control for multiple confounders related to variable timing, technique, and infection control practices. [ABSTRACT FROM AUTHOR]

Background: Older frail patients are more likely to have timely goals of care (GOC) documentation than non‐frail patients. Aims: To investigate whether timely documentation of GOC within 72 h differed in the context of the COVID‐19 pandemic (2020), compared with the pre‐COVID‐19 era (2019) for older frail patients. Methods: Multi‐site retrospective cohort study was conducted in two public hospitals where all consecutive frail adult patients aged ≥65 years were admitted under medical units for at least 24 h between 1 March 31 and October in 2019 and between 1 March and 31 October 2020 were included. The GOC was derived from electronic records. Frailty status was derived from hospital coding data using hospital frailty risk score (frail ≥5). The primary outcome was the documentation of GOC within 72 h of hospital admission. Secondary outcomes included hospital mortality, rapid response call, intensive care unit admission, prolonged hospital length of stay (≥10 days) and time to the documentation of GOC. Results: The study population comprised 2021 frail patients admitted in 2019 and 1849 admitted in 2020, aged 81.2 and 90.9 years respectively. The proportion of patients with timely GOC was lower in 2020, than 2019 (48.3% (893/1849) vs 54.9% (1109/2021); P = 0.021). After adjusting for confounding factors, patients in 2020 were less likely to receive timely GOC (odds ratio = 0.77; 95% confidence interval (CI) 0.68–0.88). Overall time to GOC documentation was longer in 2020 (hazard ratio = 0.86; 95% CI 0.80–0.93). Conclusion: Timely GOC documentation occurred less frequently in frail patients during the COVID‐19 pandemic than in the pre‐COVID‐19 era. [ABSTRACT FROM AUTHOR]

Background: Observational data during the pandemic have demonstrated mixed associations between frailty and mortality. Aim: To examine associations between frailty and short‐term mortality in patients hospitalised with coronavirus disease 2019 (COVID‐19). Methods: In this systematic review and meta‐analysis, we searched PubMed, Embase and the COVID‐19 living systematic review from 1 December 2019 to 15 July 2021. Studies reporting mortality and frailty scores in hospitalised patients with COVID‐19 (age ≥18 years) were included. Data on patient demographics, short‐term mortality (in hospital or within 30 days), intensive care unit (ICU) admission and need for invasive mechanical ventilation (IMV) were extracted. The quality of studies was assessed using the Newcastle−Ottawa Scale. Results: Twenty‐five studies reporting 34 628 patients were included. Overall, 26.2% (n = 9061) died. Patients who died were older (76.7 ± 9.6 vs 69.2 ± 13.4), more likely male (risk ratio (RR) = 1.08; 95% confidence interval (CI): 1.06–1.11) and had more comorbidities. Fifty‐eight percent of patients were frail. Adjusting for age, there was no difference in short‐term mortality between frail and non‐frail patients (RR = 1.04; 95% CI: 0.84–1.28). The non‐frail patients were commonly admitted to ICU (27.2% (4256/15639) vs 29.1% (3567/12274); P = 0.011) and had a higher mortality risk (RR = 1.63; 95% CI: 1.30–2.03) than frail patients. Among patients receiving IMV, there was no difference in mortality between frail and non‐frail (RR = 1.62; 95% CI 0.93–2.77). Conclusion: This systematic review did not demonstrate an independent association between frailty status and short‐term mortality in patients with COVID‐19. Patients with frailty were less commonly admitted to ICU and non‐frail patients were more likely to receive IMV and had higher mortality risk. This finding may be related to allocation decisions for patients with frailty amidst the pandemic. [ABSTRACT FROM AUTHOR]

Background: Hospitalised frail older patients are at risk of clinical deterioration. Early goals of care (GOC) documentation is vital to avoid futile/unwarranted interventions in the event of deterioration. Aims: To investigate the impact of frailty on timely GOC and its association with clinical outcomes in hospitalised older patients. Methods: This was a single‐centre retrospective study of all medical patients aged ≥80 years admitted to the acute medical unit between 1/3/2015 and 31/8/2015, with GOC derived from electronic records. Frailty was measured using the Hospital Frailty Risk Score (HFRS) derived from hospital coding data. Primary outcome compared proportions of timely GOC within 72‐h between frail (HFRS ≥ 5) and non‐frail (HFRS < 5) patients. Exploratory secondary outcomes included in‐hospital mortality, rapid response calls (RRC), prolonged length of stay (LOS) and 28‐day readmission rates. Results: Of the 1118 admitted patients, 529 (47.3%) were frail. Timely GOC occurred in 50% (559/1118), more commonly in frail patients (283/529, 53.5%) than non‐frail patients (276/589, 46.9%), P = 0.027. Frailty was positively associated with timely GOC independent of age and gender (odds ratio = 1.28; 95% confidence interval = 1.01–163; P = 0.041). In univariable analyses, timely GOC was associated with greater in‐hospital mortality, RRC, and hospital LOS in both frail and non‐frail patients (all P < 0.05) and greater 28‐day readmissions only among frail patients (P = 0.028). Multivariable regression demonstrated that timely GOC was associated only with in‐hospital mortality in both frail and non‐frail patients, independent of age and gender. Conclusion: Older frail hospitalised patients were more likely to have timely GOC than older non‐frail patients. Timely GOC in such patients may avoid burdensome treatments. [ABSTRACT FROM AUTHOR]

The objective of the present study is to investigate the incidence, characteristics and outcomes of patients who were readmitted to hospital emergency departments or required rehospitalisation following an index hospitalisation with a diagnosis of COVID-19. A systematic review of PubMed, EMBASE and pre-print websites was conducted between 1 January and 31 December 2020. Studies reporting on the incidence, characteristics and outcomes of patients with COVID-19 who represent or require hospital admission were included. Two authors independently performed study selection and data extraction. Study quality was assessed with the Newcastle-Ottawa Scale. Discrepancies were resolved by consensus or through an independent third reviewer. Data were synthesised according to the Preferred Reporting Items for Systematic Reviews guidelines. Six studies reporting on 547 readmitted patients were included. The overall incidence was 4.4%, most common in males (57.2%), and due to respiratory distress or prolonged COVID-19. Readmitted patients had a shorter initial hospital length of stay (LOS) compared with those with a single hospitalisation (8.1 ± 10.6 vs 13.9 ± 10.2 days). The mean time to readmission was 7.6 ± 6.0 days; the mean LOS on re-hospitalisation was 6.3 ± 5.6 days. Hypertension (odds ratio (OR) = 2.08; 95% confidence interval (CI) 1.69-2.55; P < 0.001; I² = 0%), diabetes mellitus (OR = 1.77; 95% CI 1.38-2.27; P < 0.001; I² = 0%) and chronic renal failure (OR = 2.37; 95% CI 1.09-5.14; P < 0.001; I² = 0%) were more common in these patients. Intensive care admission rates were similar between the two groups; 12.8% (22/172) of readmitted patients died. In summary, readmitted patients following an index hospitalisation for COVID-19 were more commonly males with multiple comorbidities. Shorter initial hospital LOS and unresolved primary illness may have contributed to readmission. [ABSTRACT FROM AUTHOR]

Background: To allow better allocation of staff and resources, rapid response teams attending to acutely deteriorating or aggressive patients with suspected or confirmed COVID‐19 infection were pre‐warned with the announcement of 'Code‐95' with calls. Aim: To assess healthcare worker (HCW) perspectives on pre‐warning rapid response calls (RRC) with 'Code‐95' in announcements when attending to deteriorating or aggressive patients with suspected/confirmed COVID‐19 infection. Methods: Design: prospective cross‐sectional single‐centre survey of HCW over a 3‐week period. Setting: tertiary public hospital. Participants: HCW caring for deteriorating or aggressive patients. Main outcome measures: the primary outcome was to assess HCW perspectives in attending Code‐95 calls. Secondary outcomes were to identify any differences related to craft group, age, experience or presence of comorbidities. Results: A total of 297 responses was analysed; 86.7% of HCW (n = 257) attending Code‐95 calls reported anxiety. Medical staff reported greater anxiety in comparison to nursing staff (93.8% vs 78.5%; P = 0.002). Efferent team reported higher anxiety in contrast to afferent team (92.6% vs 58.8%; P = 0.021). There was no significant difference in perceived anxiety based on age (≤40 vs >40 years of age), years of experience (≤5 vs >5 years), comorbidities or mental illness; 54% reported concerns about adequacy of infection‐control policies and personal protective equipment; 45% were worried about inadequate training for responding to Code‐95 calls. Conclusions: Most surveyed HCW supported Code‐95 announcements pre‐warning them of potential COVID‐19 exposure when attending a RRC. However, the majority of HCW reported anxiety when attending these calls. Medical and efferent team HCW perceived greater anxiety compared to nursing and afferent team HCW. The Code‐95 system to pre‐warn rapid response teams may be a useful addition to protecting HCW from infectious diseases, although broader implementation will require greater resourcing, training and support. [ABSTRACT FROM AUTHOR]

Background: The ageing of our society has led to increasing numbers of older people requiring elective surgical procedures. Preoperative frailty is a strong predictor of adverse post‐operative outcomes. This review aims to summarize the evidence for interventions aimed at improving outcomes in frail older people who may undergo elective surgery. Methods: Articles published on perioperative management of frailty between 1 January 1970 and 31 May 2019 were searched using PubMed and EMBASE. Results: We identified very few studies investigating such interventions, such as comprehensive geriatric assessment, prehabilitation (alone or as a multicomponent strategy) and other multicomponent interventions. Administration of a comprehensive geriatric assessment was shown to be associated with reduced mortality, fewer complications and shorter length of hospital stay, and may be best targeted towards those who are identified as frail for resource efficiency. Multicomponent interventions including prehabilitation may be associated with improved outcomes, but the evidence base for these needs to be strengthened. Conclusion: Establishing multidisciplinary collaborative services to provide person‐centred models of care should be considered for older people presenting for elective surgery, particularly in those with greater preoperative frailty. Further large‐scale studies should focus on implementing and evaluating such multicomponent models of care. [ABSTRACT FROM AUTHOR]

Objective: To explore associations between frailty (Clinical Frailty Scale score of 5 or more) in very old patients in intensive care units (ICUs) and their clinical outcomes (mortality, discharge destination).Design, Setting and Participants: Retrospective population cohort analysis of Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database data for all patients aged 80 years or more admitted to participating ICUs between 1 January 2017 and 31 December 2018.Main Outcome Measures: Primary outcome: in-hospital mortality; secondary outcomes: length of stay (hospital, ICU), re-admission to ICU during the same hospital admission, discharge destination (including new chronic care or nursing home admission).Results: Frailty status data were available for 15 613 of 45 773 patients aged 80 years or more admitted to 178 ICUs (34%); 6203 of these patients (39.7%) were deemed frail. A smaller proportion of frail than non-frail patients were men (47% v 57%), the mean illness severity scores of frail patients were slightly higher than those of non-frail patients, and they were more frequently admitted from the emergency department (28% v 21%) or with sepsis (12% v 7%) or respiratory complications (16% v 12%). In-hospital mortality was higher for frail patients (17.6% v 8.2%; adjusted odds ratio [OR], 1.87 [95% CI, 1.65-2.11]). Median lengths of ICU and hospital stay were slightly longer for frail patients, and they were more frequently discharged to new nursing home or chronic care (4.9% v 2.8%; adjusted OR, 1.61 [95% CI, 1.34-1.95]).Conclusions: Many very old critically ill patients in Australia and New Zealand are frail, and frailty is associated with considerably poorer health outcomes. Routine screening of older ICU patients for frailty could improve outcome prediction and inform intensive care and community health care planning. [ABSTRACT FROM AUTHOR]

Background: Improved life‐expectancies have seen increased rates of older patients undergoing surgery worldwide. These patients are at increased risk of post‐operative complications. Australian evidence is limited regarding the association between age and post‐operative outcomes, especially rapid response calls (RRCs) as indicators of adverse outcomes. The aim was to compare the post‐operative outcomes of older patients (≥80 years) to younger patients. Specifically, 30‐day in‐hospital mortality; unplanned intensive care unit (ICU) admission; and RRC activation within 72 h post‐operatively. Methods: Single‐centre retrospective observational study conducted over 12 months in a metropolitan Australian hospital. All adult patients (≥16 years) undergoing surgical procedures were included, excluding cardiac and obstetric/gynaecological surgeries. Patient co‐morbidities were quantified using Charlson co‐morbidity index (CCI) and American Society of Anesthesiologists physical status classification. Results: Seven thousand four hundred and seventy‐nine patients met inclusion criteria, 14.5% (n = 1086) aged ≥80 years. Most procedures (65%) were elective; and general surgical procedures were most common (24.2%). Compared to younger patients, older patients had significantly higher 30‐day mortality (2.3% versus 0.2%; P < 0.001), increased post‐operative RRC rates (7.3% versus 1.2%; P < 0.001), and unplanned ICU admissions (3.2% versus 1.6%; P < 0.001). Increasing age was associated with increased risk of post‐operative RRC, unplanned ICU admission, and in‐hospital mortality (all P < 0.01), with associations remaining significant after controlling for surgery type and CCI. Conclusion: Older patients are at increased risk of adverse post‐operative outcomes, including post‐operative RRC, unplanned ICU admission, and mortality, especially if they underwent emergency procedures. This has implications for preoperative risk stratification and post‐operative management. Incidence of post‐operative RRCs may be an important indicator of post‐operative care. [ABSTRACT FROM AUTHOR]

Objective: To systematically review the literature regarding the ability of clinical features to predict respiratory failure in patients with Guillain–Barré syndrome (GBS). Data sources: We searched the PubMed and Ovid MEDLINE databases with the search terms "guillain barre syndrome" OR "acute inflammatory demyelinating polyneuropathy" OR "acute motor axonal neuropathy" OR "acute motor sensory axonal neuropathy" AND "respiratory failure" OR "mechanical ventilation". We excluded articles that did not report the results of original research (eg, review articles, letters), were case reports or series (ten or fewer patients), were not available in English, reported research in paediatric populations (16 years of age or younger), or were interventional studies. Article quality was assessed with the Newcastle–Ottawa quality assessment scale. Data synthesis: Thirty‐four relevant studies were identified. Short time from symptom onset to hospital admission (less than 7 days), bulbar (odds ratio [OR], 9.0; 95% CI, 3.94–20.6; P < 0.001) or neck weakness (OR, 6.36; 95% CI, 2.32–17.5; P < 0.001), and severe muscle weakness at hospital admission were associated with increased risk of intubation. Facial weakness (OR, 3.74; 95% CI, 2.05–6.81; P < 0.001) and autonomic instability (OR, 6.40; 95% CI, 2.83–14.5; P < 0.001) were significantly more frequent in patients requiring intubation in our meta‐analyses; however, the differences were not statistically significant in individual multivariable analysis studies. Four predictive models have been developed to assess the risk of respiratory failure for patients with GBS, each with good to excellent discriminative power (area under the receiver operating characteristic curve, 0.79–0.96). Conclusions and relevance: Early identification of GBS patients at risk of respiratory failure could reduce the rates of adverse outcomes associated with delayed intubation. Algorithms that predict a patient's risk of subsequent respiratory failure at hospital admission appear more reliable than individual clinical variables. [ABSTRACT FROM AUTHOR]

Key Clinical Message Spinal infarction is a rare and devastating complication of open-heart surgery, especially in the context of perioperative hemodynamic instability in patients requiring high dose of inotropes and vasoconstrictors. Our report highlights that spinal infarction can occur in such circumstances following a valve replacement surgery. [ABSTRACT FROM AUTHOR]