Lahn Straney

Paediatric index of mortality 3: An updated model for predicting mortality in pediatric intensive care

Objectives: To provide an updated version of the Paediatric Index of Mortality 2 for assessing the risk of mortality among children admitted to an ICU. Design: International, multicenter, prospective cohort study. Setting: Sixty ICUs that accept pediatric admissions in Australia, New Zealand, Ireland, and the United Kingdom. Patients: All children admitted in 2010 and 2011 younger than 18 years old at the time of admission and either died in ICU or were discharged. Patients who were transferred to another ICU were not included. Fifty-three thousand one hundred twelve patient admissions were included in the analysis. Interventions: None. Measurement and Main Results: A revised prediction model was built using logistic regression. Variable selection was based on significance at the 95% level and overall improvement of the model’s discriminatory performance and goodness of fit. The final model discriminated well (area under the curve, 0.88, 0.88–0.89); however, the model performed better in Australia and New Zealand than in the United Kingdom and Ireland (area under the curve was 0.91, 0.90–0.93 and 0.85, 0.84–0.86, respectively). Conclusions: Paediatric Index of Mortality 3 provides an international standard based on a large contemporary dataset for the comparison of risk-adjusted mortality among children admitted to intensive care.

Mortality related to invasive infections, sepsis, and septic shock in critically ill children in Australia and New Zealand, 2002–13: a multicentre retrospective cohort study

BACKGROUND Severe infections kill more than 4·5 million children every year. Population-based data for severe infections in children requiring admission to intensive care units (ICUs) are scarce. We assessed changes in incidence and mortality of severe infections in critically ill children in Australia and New Zealand. METHODS We did a retrospective multicentre cohort study of children requiring intensive care in Australia and New Zealand between 2002 and 2013, with data from the Australian and New Zealand Paediatric Intensive Care Registry. We included children younger than 16 years with invasive infection, sepsis, or septic shock. We assessed incidence and mortality in the ICU for 2002-07 versus 2008-13. FINDINGS During the study period, 97 127 children were admitted to ICUs, 11 574 (11·9%) had severe infections, including 6688 (6·9%) with invasive infections, 2847 (2·9%) with sepsis, and 2039 (2·1%) with septic shock. Age-standardised incidence increased each year by an average of 0·56 cases per 100 000 children (95% CI 0·41-0·71) for invasive infections, 0·09 cases per 100 000 children (0·00-0·17) for sepsis, and 0·08 cases per 100 000 children (0·04-0·12) for septic shock. 260 (3·9%) of 6688 patients with invasive infection died, 159 (5·6%) of 2847 with sepsis died, and 346 (17·0%) of 2039 with septic shock died, compared with 2893 (3·0%) of all paediatric ICU admissions. Children admitted with invasive infections, sepsis, and septic shock accounted for 765 (26·4%) of 2893 paediatric deaths in ICUs. Comparing 2008-13 with 2002-07, risk-adjusted mortality decreased significantly for invasive infections (odds ratio 0·72, 95% CI 0·56-0·94; p=0·016), and for sepsis (0·66, 0·47-0·93; p=0·016), but not significantly for septic shock (0·79, 0·61-1·01; p=0·065). INTERPRETATION Severe infections remain a major cause of mortality in paediatric ICUs, representing a major public health problem. Future studies should focus on patients with the highest risk of poor outcome, and assess the effectiveness of present sepsis interventions in children. FUNDING National Medical Health and Research Council, Australian Resuscitation Outcomes Consortium, Centre of Research Excellence (1029983).

Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multigroup, randomised controlled trial

BACKGROUND The excruciating pain of patients with renal colic on presentation to the emergency department requires effective analgesia to be administered in the shortest possible time. Trials comparing intramuscular non-steroidal anti-inflammatory drugs with intravenous opioids or paracetamol have been inconclusive because of the challenges associated with concealment of randomisation, small sample size, differences in outcome measures, and inadequate masking of participants and assessors. We did this trial to develop definitive evidence regarding the choice of initial analgesia and route of administration in participants presenting with renal colic to the emergency department. METHODS In this three-treatment group, double-blind, randomised controlled trial, adult participants (aged 18-65 years) presenting to the emergency department of an academic, tertiary care hospital in Qatar, with moderate to severe renal colic (Numerical pain Rating Scale ≥ 4) were recruited. With the use of computer-generated block randomisation (block sizes of six and nine), participants were assigned (1:1:1) to receive diclofenac (75 mg/3 mL intramuscular), morphine (0.1 mg/kg intravenous), or paracetamol (1 g/100 mL intravenous). Participants, clinicians, and trial personnel were masked to treatment assignment. The primary outcome was the proportion of participants achieving at least a 50% reduction in initial pain score at 30 min after analgesia, assessed by intention-to-treat analysis and per-protocol analysis, which included patients where a calculus in the urinary tract was detected with imaging. This trial is registered with ClinicalTrials.gov, number NCT02187614. FINDINGS Between Aug 5, 2014, and March 15, 2015, we randomly assigned 1645 participants, of whom 1644 were included in the intention-to-treat analysis (547 in the diclofenac group, 548 in the paracetemol group, and 549 in the morphine group). Ureteric calculi were detected in 1316 patients, who were analysed as the per-protocol population (438 in the diclofenac group, 435 in the paracetemol group, and 443 in the morphine group). The primary outcome was achieved in 371 (68%) patients in the diclofenac group, 364 (66%) in the paracetamol group, and 335 (61%) in the morphine group in the intention-to-treat population. Compared to morphine, diclofenac was significantly more effective in achieving the primary outcome (odds ratio [OR] 1·35, 95% CI 1·05-1·73, p=0·0187), whereas no difference was detected in the effectiveness of morphine compared with intravenous paracetamol (1·26, 0·99-1·62, p=0·0629). In the per-protocol population, diclofenac (OR 1·49, 95% CI 1·13-1·97, p=0·0046) and paracetamol (1·40, 1·06-1·85, p=0·0166) were more effective than morphine in achieving the primary outcome. Acute adverse events in the morphine group occurred in 19 (3%) participants. Significantly lower numbers of adverse events were recorded in the diclofenac group (7 [1%] participants, OR 0·31, 95% CI 0·12-0·78, p=0·0088) and paracetamol group (7 [1%] participants, 0·36, 0·15-0·87, p=0·0175) than in the morphine group. During the 2 week follow-up, no additional adverse events were noted in any group. INTERPRETATION Intramuscular non-steroidal anti-inflammatory drugs offer the most effective sustained analgesia for renal colic in the emergency department and seem to have fewer side-effects. FUNDING Hamad Medical Corporation Medical Research Center, Doha, Qatar.

Regions of High Out-Of-Hospital Cardiac Arrest Incidence and Low Bystander CPR Rates in Victoria, Australia

Background Out-of-hospital cardiac arrest (OHCA) remains a major public health issue and research has shown that large regional variation in outcomes exists. Of the interventions associated with survival, the provision of bystander CPR is one of the most important modifiable factors. The aim of this study is to identify census areas with high incidence of OHCA and low rates of bystander CPR in Victoria, Australia Methods We conducted an observational study using prospectively collected population-based OHCA data from the state of Victoria in Australia. Using ArcGIS (ArcMap 10.0), we linked the location of the arrest using the dispatch coordinates (longitude and latitude) to Victorian Local Government Areas (LGAs). We used Bayesian hierarchical models with random effects on each LGA to provide shrunken estimates of the rates of bystander CPR and the incidence rates. Results Over the study period there were 31,019 adult OHCA attended, of which 21,436 (69.1%) cases were of presumed cardiac etiology. Significant variation in the incidence of OHCA among LGAs was observed. There was a 3 fold difference in the incidence rate between the lowest and highest LGAs, ranging from 38.5 to 115.1 cases per 100,000 person-years. The overall rate of bystander CPR for bystander witnessed OHCAs was 62.4%, with the rate increasing from 56.4% in 2008–2010 to 68.6% in 2010–2013. There was a 25.1% absolute difference in bystander CPR rates between the highest and lowest LGAs. Conclusion Significant regional variation in OHCA incidence and bystander CPR rates exists throughout Victoria. Regions with high incidence and low bystander CPR participation can be identified and would make suitable targets for interventions to improve CPR participation rates.

Evaluating the impact of air pollution on the incidence of out-of-hospital cardiac arrest in the Perth Metropolitan Region: 2000–2010

Background Out-of-hospital cardiac arrest (OHCA) remains a major public health issue. Several studies have found that an increased level of ambient particulate matter (PM) smaller than 2.5 microns (PM2.5) is associated with an increased risk of OHCA. We investigated the relationship between air pollution levels and the incidence of OHCA in Perth, Western Australia. Methods We linked St John Ambulance OHCA data of presumed cardiac aetiology with Perth air pollution data from seven monitors which recorded hourly levels of PM smaller than 2.5 and 10 microns (PM2.5/PM10), carbon monoxide (CO), sulfur dioxide (SO2), nitrogen dioxide (NO2) and ozone (O3). We used a case-crossover design to estimate the strength of association between ambient air pollution levels and risk of OHCA. Results Between 2000 and 2010, there were 8551 OHCAs that met the inclusion criteria. Of these, 5624 (65.8%) occurred in men. An IQR increase in the 24 and 48 h averages of PM2.5 was associated with 10.6% (OR 1.106, 95% CI 1.038 to 1.180) and 13.6% (OR 1.136, 95% CI 1.051 to 1.228) increases, respectively, in the risk of OHCA. CO showed a consistent association with increased risk of an OHCA. An IQR increase in the 4 h average concentration of CO was associated with a 2.2% (OR 1.022, 95% CI 1.002 to 1.042) increase in risk of an OHCA. When we restricted our analysis of CO to arrests occurring between 6:00 and 10:00, we found a 4.4% (95% CI 1.1% to 7.8%) increase in risk of an OHCA. Conclusions Elevated ambient PM2.5 and CO are associated with an increased risk of OHCA.

Mass Media Campaigns’ Influence on Prehospital Behavior for Acute Coronary Syndromes: An Evaluation of the Australian Heart Foundation's Warning Signs Campaign

Background The aim of this study was to examine the awareness of a recent mass media campaign, and its influence on knowledge and prehospital times, in a cohort of acute coronary syndrome (ACS) patients admitted to an Australian hospital. Methods and Results We conducted 199 semistructured interviews with consecutive ACS patients who were aged 35 to 75 years, competent to provide consent, and English speaking. Questions addressed the factors known to predict prehospital delay, awareness of the campaign, and whether it increased knowledge and influenced actions. Multivariable logistic regression was used to examine the association between campaign awareness and a 1-hour delay in deciding to seek medical attention (patient delay) and a 2-hour delay in presenting to hospital (prehospital delay). The median age was 62 years (IQR=53 to 68 years), and 68% (n=136) were male. Awareness of the campaign was reported by 127 (64%) patients, with most of these patients stating the campaign (1) increased their understanding of what is a heart attack (63%), (2) increased their awareness of the signs and symptoms of heart attack (68%), and (3) influenced their actions in response to symptoms (43%). After adjustment for other predictors, awareness of the campaign was significantly associated with patient delay time of ≤1 hour (adjusted odds ratio [AOR]=2.25, 95% CI: 1.03 to 4.91, P=0.04) and prehospital delay time ≤2 hours (AOR=3.11, 95% CI: 1.36 to 7.08, P=0.007). Conclusions Our study showed reasonably high awareness of the warning signs campaign, which was significantly associated with shorter prehospital decision-making and faster presentation to hospital.

Trends in the incidence of presumed cardiac out-of-hospital cardiac arrest in Perth, Western Australia, 1997–2010

AIM This study investigated temporal trends in the incidence of out-of-hospital cardiac arrests (OHCA) in metropolitan Perth (Western Australia) between 1997 and 2010. METHODS We calculated crude and age-and-sex-standardised incidence rates (ASIRs) using the 2011 Australian population as the standard population. Incidence rates are reported per 100,000 population, and for eight age categories (0-14, 15-34, 35-64, 65-69, 70-74, 75-79, 80-84, ≥85). Temporal trends were analysed with linear regression. RESULTS Over the 14-years, 12,421 OHCAs of presumed cardiac aetiology were attended by St John Ambulance Western Australia paramedics. The overall ASIR per 100,000 population decreased significantly over this time (75.7-70.6, p<0.001), but predominantly between 1997 and 2002 (75.7-65.9) and in those aged ≥65 years (410.2-336.7, p<0.001). This trend was observed for both males and females and across all five-year age-groups between 65 and 84 years, but not in those ≥85 years--whom by 2010 represented 30% of the older adult (65+ years) OHCAs attended, up from 16% in 1997 (p<0.001). CONCLUSIONS Over the study period, a decline in the ASIR for OHCAs of presumed cardiac aetiology in Perth was observed. This is largely attributed to a decreasing incidence in the population aged 65-84 years between 1997 and 2002, and is likely the result of improvements in cardiovascular risk profiles that have previously been reported among Western Australian adults. Future studies of the impact of the ageing population are required.

Trends in traumatic out-of-hospital cardiac arrest in Perth, Western Australia from 1997 to 2014

AIM This study aims to describe and compare traumatic and medical out-of-hospital cardiac arrest (OHCA) occurring in Perth, Western Australia, between 1997 and 2014. METHODS The St John Ambulance Western Australia (SJA-WA) OHCA Database was used to identify all adult (≥ 16 years) cases. We calculated annual crude and age-sex standardised incidence rates (ASIRs) for traumatic and medical OHCA and investigated trends over time. RESULTS Over the study period, SJA-WA attended 1,354 traumatic OHCA and 16,076 medical OHCA cases. The mean annual crude incidence rate of traumatic OHCA in adults attended by SJA-WA was 6.0 per 100,000 (73.9 per 100,000 for medical cases), with the majority resulting from motor vehicle collisions (56.7%). We noted no change to either incidence or mechanism of injury over the study period (p>0.05). Compared to medical OHCA, traumatic OHCA cases were less likely to receive bystander cardiopulmonary resuscitation (CPR) (20.4% vs. 24.5%, p=0.001) or have resuscitation commenced by paramedics (38.9% vs. 44.8%, p<0.001). However, rates of bystander CPR and resuscitation commenced by paramedics increased significantly over time in traumatic OHCA (p<0.001). In cases where resuscitation was commenced by paramedics there was no difference in the proportion who died at the scene (37.2% traumatic vs. 34.3% medical, p=0.17), however, fewer traumatic OHCAs survived to hospital discharge (1.7% vs. 8.7%, p<0.001). CONCLUSIONS Despite temporal increases in rates of bystander CPR and paramedic resuscitation, traumatic OHCA survival remains poor with only nine patients surviving from traumatic OHCA over the 18-year period.

Unplanned early return to the emergency department by older patients: the Safe Elderly Emergency Department Discharge (SEED) project

BACKGROUND an emergency department (ED) visit is a sentinel event for an older person, with increased likelihood of adverse outcomes post-discharge including early re-presentation. OBJECTIVES to determine factors associated with early re-presentation. METHODS prospective cohort study conducted in the ED of a large acute Melbourne tertiary hospital. Community-dwelling patients ≥65 years were interviewed including comprehensive assessment of cognitive and functional status, and mood. Logistic regression was used to identify risk factors for return within 30 days. RESULTS nine hundred and fifty-nine patients, median age 77 years, were recruited. One hundred and forty patients (14.6%) re-presented within 30 days, including 22 patients (2.3%) on ≥2 occasions and 75 patients (7.8%) within 7 days. Risk factors for re-presentation included depressive symptoms, cognitive impairment, co-morbidity, triaged as less urgent (ATS 4) and attendance in the previous 12 months, with a decline in risk after 85 years of age. Logistic regression identified chronic obstructive pulmonary disease (OR 1.78, 95% CI 1.02-3.11), moderate cognitive impairment (OR 2.07, 95% CI 1.09-3.90), previous ED visit (OR 2.11, 95% CI 1.43-3.12) and ATS 4 (OR 2.34, 95% CI 1.10-4.99) as independent risk factors for re-presentation. Age ≥85 years was associated with reduced risk (OR 0.81, 95% CI 0.70-0.93). CONCLUSION older discharged patients had a high rate of early re-presentation. Previously identified risk factors-increased age, living alone, functional dependence and polypharmacy-were not associated with early return in this study. It is not clear whether these inconsistencies represent a change in patient case-mix or strategies implemented to reduce re-attendance. This remains an important area for future research.

Redesigning emergency patient flow with timely quality care at the Alfred

The 4 h National Emergency Access Target was introduced in 2011. The Alfred Hospital in Melbourne implemented a hospital‐wide clinical service framework, Timely Quality Care (TQC), to enhance patient experience and care quality by improving timeliness of interventions and investigations through the emergency episode and admission to discharge in 2012. We evaluated TQCs effect on achieving the National Emergency Access Target and associated safety and quality indicators.