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Objectives: To describe the effect of a communication skills training programme on patient-centred goals of care documentation and clinical outcomes in critically ill patients with life-limiting illnesses (LLI) referred for intensive care management., Methods: Prospective before-and-after cohort study in a tertiary teaching hospital in Australia. The population was 222 adult patients with LLI referred to the intensive care unit (ICU). The study was divided into two periods, before (1 May to 31 July 2015) and after (15 September to 15December 2015) the intervention. The intervention was a 2-day, small group, simulated-patient, communication skills course, and process of care for patients with LLI. The primary outcome was documentation of patient-centred goals of care discussion (PCD) within 48 hours of referral to the ICU. Secondary outcomes included clinical outcomes and 90-day mortality., Results: The intervention was associated with increased documentation of a PCD from 50% to 69% (p=0.004) and 43% to 94% (p<0.0001) in patients deceased by day 90. A significant decrease in critical care as the choice of resuscitation goal (61% vs 42%, p=0.02) was observed. Although there was no decrease in admission to ICU, there was a significant decrease in medical emergency team call prevalence (87% vs 73%, p=0.009). The cancer and organ failure groups had a significant decrease in 90-day mortality (75% vs 44%, p=0.02; 42% vs 16%, p=0.01), and the frailty group had a significant decrease in 90-day readmissions (48% vs 19%, p=0.003)., Conclusions: The intervention was associated with increased PCD documentation and decrease in the choice of critical care as the resuscitation goal. Admissions to ICU did not decrease, and although limited by study design, condition-specific trajectory changes, clinical interventions and outcomes warrant further study., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: To describe the prevalence, characteristics, long-term outcomes and goals-of-care discussions of patients with objective indicators of life-limiting illnesses (LLIs) referred to the intensive care unit., Design, Setting and Patients: A prospective, observational, cohort study of all adult inpatients referred to the ICU by the medical emergency team or by direct referral, during the period 30 August 2012 to 1 February 2013, at a tertiary teaching hospital in Australia., Main Outcome Measures: Mortality, LLIs, discharge destination and documentation on goals of care in medical record., Results: A total of 649 of 1024 patients referred to the ICU had an LLI, and only 34.4% of these patients had goals of care documented. Overall, 49.2% were admitted to the ICU, 48.4% were discharged home, and the 1-year mortality was 35.1%. The most common LLI criteria were heart disease (52.2%), chronic obstructive pulmonary disease (24.8%) and frailty (23.7%). The highest 1-year mortality was associated with pre-hospital residence in a nursing home (64.9%), dementia (63.3%), cancer (60.8%) and frailty (50.6%). Analysis of patients by clinical trajectory showed that 1-year mortality was significantly higher for patients with cancer (59.6%), combined organ failure and frailty (47.3%), frailty (43.8%) and organ failure (23.6%), compared with patients with no LLI (P < 0.0001)., Conclusions: A high proportion of patients referred to the ICU have an LLI, and this is associated with prolonged hospital length of stay and a high 1-year mortality, and only one-quarter have documented discussions on goals of care. Patients with cancer-related and frailty-related LLIs have the worst survival trajectories.

Daily hemofiltration circuit management in Australian ICUs is a nursing activity predominantly utilizing venovenous access and a BMM 10-1 (Gambro, Lund, Sweden) blood pump. The design of the hemofiltration circuit should enable the easy addition of replacement fluids, the administration of anticoagulant drugs, and the collection of ultrafiltrate (UF). The ability to measure circuit pressures both before and after the filter may assist in the understanding of circuit dynamics and the prediction of filter dysfunction. Ultrafiltration (vol/hr) can be maximized using readily available intravenous pumps; however, the limitations of this (i.e., volume accuracy) need to be considered. The day-to-day nursing management of patients undergoing continuous venovenous hemofiltration (CVVH) requires continuous assessment and monitoring to prevent complications associated with fluid/electrolyte imbalance, blood and heat loss, infection, poor UF production, and foreign substance reaction. We have found that the nursing staff, therefore, requires a variety of educational strategies to gain expertise and, thus, provide a high standard of nursing management for this therapy. Quality assurance is also a necessary adjunct to the safe and efficient use of CVVH.